Choose the correct answer: 30 Marks

1) 80-year-old patient is returning to the gynecologist’s office for pessory cleaning. Patient offers no complaints. The
nurse removes and cleans the pessory, vagina is swabbed with betadine, and pessory replaced. For F/U in 4 months.
What CPT® and ICD-9 should be used for this service?

A. 99201, Z46.59 B. 99211, Z45.89 C. 99202, Z48.01 D. 99212, Z48.02

2) Patient was in the ER complaining of constipation with nausea and vomiting when taking Zovirax for his herpes zoster
and Percocet for pain. His primary care physician came to the ER and admitted him to the hospital for intravenous
therapy and management of this problem. His physician documented a detailed history, comprehensive examination
and a medical decision making of moderate complexity. Which E/M service is reported?

A. 99285 B. 99284 C. 99221 D. 99222

3) 20-day-old infant was seen in the ER by the neonatologist admitting the baby to NICU for cyanosis and rapid
breathing. The neonatologist performed intubation, ventilation management and a complete echocardiogram in the
NICU and provided a report for the echocardiography which did indicate congenital heart disease. Select the correct
code(s) for the physician service.

A. 99468-25, 93303-26 B. 99471-25, 31500, 94002, 93303

C. 99460-25, 31500, 94002, 93303 D. 99291-25, 93303

4) 50-year-old patient is coming to see her primary care physician for hypertension. Her physician performs an expanded
problem focused exam and low medical decision making. After the exam the patient discusses with her physician that
the OBGYN office had just told her that her Pap smear came back with an abnormal reading and is worried since her
aunt had passed away with cervical cancer. The physician spends an extra 45 minutes face-to-face time discussing with
her the awareness, other screening procedures and treatment if it turns out to be cervical cancer. What code(s) should
be used for this visit?
A. 99215
B. 99213, 99354
C. 99213
D. 99213, 99403

5) A patient was admitted yesterday to the hospital for possible gallstones. The following day the physician who
admitted the patient performed a detailed history, a detailed exam and a medical decision making of low complexity.
The physician tells her the test results have come back positive for gallstones and is recommending having a
cholecystectomy. What code should be reported for this evaluation and management service?

A. 99253
B. 99221
C. 99233
D. 99234

6) A patient came in to the ER with wheezing and a rapid heart rate. The ER physician documents a comprehensive
history, comprehensive exam and medical decision of moderate complexity. The patient has been given three nebulizer
treatments. The ER physician has decided to place him in observation care for the acute asthma exacerbation. The ER
physician will continue examining the patient and will order additional treatments until the wheezing subsides. Select
the appropriate code(s) for this visit.

A. 99284, 99219

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B. 99219
C. 99284
D. 99235

7) Patient is here to follow up on her atrial fibrillation. Her primary care physician is not in the office. She will be seen by
the partner physician that is also in the same practice. No new problems. Blood pressure is 110/64. Pulse is regular at
72. Temp is 98.6F Chest is clear. Cardiac normal sinus rhythm. Medical making decision is straightforward. Diagnosis:
Atrial fibrillation, currently stable. What CPT® code is reported for this service?
A. 99201
B. 99202
C. 99212
D. 99213

8) Documentation of a new patient in a doctor’s office setting supports the History in four elements for an extended
history of present illness (HPI), three elements for an extended review of systems (ROS) and three elements for a
complete Past, Family, Social History (PFSH) . There is an extended examination of six body areas and organ systems. The
medical making decision making is of high complexity. Which E/M service supports this documentation?

A. 99205
B. 99204
C. 99203
D. 99202

9) Two-year-old is brought to the ER by EMS for near drowning. EMS had gotten a pulse. The ER physician performs
endotracheal intubation, blood gas, and a central venous catheter placement. The ER physician documents a total time
of 30 minutes on this critical infant in which the physician already subtracted the time for the other billable services.
Select the E/M service and procedures to report for the ER physician?

A. 99291-25, 36555, 31500

B. 99291, 36556, 31500, 82803
C. 99285-25, 36556, 31500, 82803
D. 99475, 36556

10) 2-year-old is coming in with his mom to see the pediatrician for fever, sore throat, and pulling of the ears. The
physician performs a brief history along with a problem pertinent review of systems. A limited exam was performed on
the ears, nose and throat and respiratory systems. A strep culture was taken and came back positive. A diagnosis was
also made of the infant having acute otitis media with effusion. The medical decision making was of moderate
complexity with the giving of a prescription. What CPT® and ICD-9-CM codes should be reported?

A. 99212, J01.1, H65.00

B. 99213, J02.9, H65.9
C. 99212, J02.9, H65.9
D. 99213, J02.9, H65.19

11) How does the CPT Professional Edition define a new patient?
a. A new patient is one who has not received any professional services from the physician or another physician of the
same specialty who belongs to the same group practice, within the past two years.
b. A new patient is one who has not received any professional services from the physician or another physician of the
same specialty who belongs to the same group practice, within the past three years.
c. A new patient is one who has received professional services from the physician or another physician of the same
specialty within the last two years for the same problem.

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d. A new patient is one who has received hospital services but has never been seen in the clinic by the reporting
physician.

12. James, a 35-year-old new patient, received 45 minutes of counseling and risk factor reduction intervention services
from Dr. Kelly. Dr. Kelly talked to James about how to avoid sports injuries. Currently, James does not have any
symptoms or injuries and wants to maintain this status would you report this.This was the only service rendered. How
service?
a. 99213
b. 99203
c. 99385
d. 99403

13. Andrea, a 52-year-old patient, had a hysterectomy on Monday morning. That afternoon, after returning to her
hospital room, she suffered a cardiac arrest. A cardiologist responded to the call and delivered one hour and 35 minutes
of critical care. During this time the cardiologist ordered a single view chest x-ray and provided ventilation management.
How should you report the cardiologist’s services?
a. 99291, 99292
b. 99291, 99292, 71010, 94002
c. 71010, 94002, 99231
d. 99291, 99292, 99292-52

14. Brandon was seen in Dr. Shaw’s office after falling off his bunk bed. Brandon’s mother reported that Brandon and his
sister were jumping on the beds when she heard a “thud.” Brandon complained of knee pain and had trouble walking.
Dr. Shaw ordered a knee x-ray that was done at the imaging center across the street. The x-ray showed no fracture or
dislocations. Dr. Shaw had seen Brandon for his school physical six months ago. Today, Dr. Shaw documented a detailed
examination and decision-making of moderate complexity. He also instructed Brandon’s mother that if Brandon had any
additional pain or trouble walking he should see an orthopedic specialist. How should Dr. Shaw report her services from
today’s visit?
a. 99204
b. 99394, 99214
c. 99214
d. 99203

15. Adam, a 48-year-old patient, presented to Dr. Crampon’s office with complaints of fever, malaise, chills, chest pain,
and a severe cough. Dr. Crampon took a history, did an exam, and ordered a chest x-ray. After reviewing the x-ray, Dr.
Crampon admitted Adam to the hospital for treatment of pneumonia. After his regular office hours, Dr. Crampon visited
Adam in the hospital where he dictated a comprehensive history, comprehensive examination, and decision-making of
moderate complexity. How would you report Dr. Crampon’s services?
a. 99214
b. 99222
c. 99204, 99222-51
d. 99223, 99214-21

16. Why are the following codes not reported with continuing intensive care services (99478–99480): 36510, 36000,
43752, 51100, 94660, or 94375?
a. These codes are deleted from the 2008 edition.
b. These codes are included with continuing intensive care services.
c. These codes are only add-on codes and should be reported with a modifier -51
d. These codes are Category III Codes and should never be reported with Category I codes.

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17. Larry is being managed for his warfarin therapy on an outpatient basis. Dr. Nancy continues to review Larry’s INR
tests, gives patient instructions, dosage adjustment as needed, and ordered additional tests. How would you report the
initial 90 days of therapy including 8 INR measurements?
a. 99363
b. 99204
c. 99214
d. This services is bundled with evaluation and management services

18. Dr. Jane admitted a 67-year-old woman to the coronary care unit for an acute myocardial infarction. The admission
included a comprehensive history, comprehensive examination, and high complexity decision-making. Dr. Jane visited
the patient on days two and three and documented (each day) an expanded problem focused examination and decision-
making of moderate complexity. On day four, Dr. Jane moved the patient to the medical floor and documented a
problem focused examination and straightforward decision-making. Day five, Dr. Jane discharged the patient to home.
The discharge took over an hour. How would you report the services from day one to day five?
a. 99213, 99232, 99231, 99239 x 2
b. 99221, 99222, 99223, 99238
c. 99231, 99232, 99355, 99217
d. 99223, 99232, 99232, 99231, 99239

19. Which code range would describe services for a critically ill patient who is 23 days old as a out patient?
a. 99291–99292
b. 99468–99469
c. 99466–99467
d. None of the above

20. Mr. Johnson, a 38-year-old established patient is being seen for management of his hypertension, diabetes, and
weight control. On his last visit, he was told he had a diabetic foot ulcer and needed to be hospitalized for this condition.
He decided to get a second opinion and went to see Dr. Myers. This was the first time Dr. Myers had seen Mr. Johnson.
Dr. Myers documented a comprehensive history, comprehensive examination, and decision-making of high complexity.
He concurred with hospitalization for the foot ulcer and sent a report back to Mr. Johnson’s primary care doctor. How
would you report Dr. Myers visit?
a. 99245
b. 99205
c. 99215
d. 99255

21. How does the CPT Professional Edition define an emergency department?
a. An organized hospital-based facility for the provision of unscheduled episodic services to patients who present for
immediate medical attention. The facility must be available 24 hours a day.
b. An organized hospital-based facility for the provision of scheduled episodic services to patients who present for
immediate medical attention. The facility must be available 24 hours a day.
c. An organized hospital-based facility for the care and treatment of chronically ill patients who present for services. The
facility must be available on weekends and holidays.
d. An organized outpatient-based facility for the care and treatment of unscheduled patient who present for immediate
medical attention. The facility must be available 24 hours a day.

22. Lucus, a three-year-old new patient is seen for a well-child examination. The doctor documents an age appropriate
history, examination, anticipatory guidelines, risk factor reduction intervention, and indicates Lucus’ immunizations are
up to date. How would you report this service?
a. 99392
b. 99213-25, 99385

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c. 99203
d. 99382

23. 42-year-old woman is being discharged today, 2/5/XX. She was admitted to the hospital 2/2/XX for acute
diverticulitis. Refer to dictated notes for a detailed description of the history, exam, and assessment and treatment
protocol. Patient was also seen in consultation by Dr Z. She was placed on intravenous antibiotics and has made slow
steady progress. Today has no abdominal pain. Labs are normal and CT of the abdomen and pelvis showed changes
consistent with diverticulitis in the left side of colon. She was given follow up instructions of her medications, what diet
to have and to follow up with PCP in 10 to 14 days or return if pain resumes. Total time spent with patient 40 minutes.
What CPT® code(s) should be reported?
A. 99233, 99239 B. 99217
C. 99252, 99238 D. 99239

24. 63-year-old man is coming in for a second opinion for his sleep apnea. He has had it for the past five months. Sleep is
disrupted by frequent awakenings and getting worse due to anxiety and snoring. He feels tired all the time, has some
joint stiffness and night sweats; all other systems were negative. He is going through a divorce which is causing him
anxiety and had a hernia repair two month ago. Doctor performs a comprehensive exam and orders labs and a sleep
study test. Prescription was given to help with the anxiety. What CPT® code should be reported?
A. 99203 B. 99204
C. 99244 D. 99214

25. A 55-year-old established patient is coming in for a pre-op visit; he is getting a liver transplant due to cirrhosis. The
physician performs an expanded problem focused history, detailed examination, and moderate MDM. Patient agrees
with his physician’s recommendations and the transplantation will take place as scheduled. After the evaluation, the
patient expresses a number of concerns and questions for the prospective liver transplant. Physician spends an
additional 30 minutes, excluding the time spent in doing the E/M service, in counseling and answering questions
regarding the surgery and discussing possible outcomes. What CPT® codes should be reported?
A. 99213, 99354 B. 99214, 99358
C. 99213, 99358 D. 99214, 99354

26. Physician performs a medical review and documentation on an 83-year-old patient still hospitalized for confusion for
the last two days. She is alert and oriented x 3 today. Reviewing her labs from yesterday, her BNP was elevated
suspecting her confusion is due to congestive heart failure. An echocardiogram is ordered and treatment will be for
congestive heart failure. Patient is not safe to return home. What CPT® code should be reported?
A. 99231 B. 99221
C. 99218 D. 99232

27. A plastic surgeon is called to the ED at the request of the emergency department physician to evaluate a patient that
arrived with multiple facial fractures after being in an automobile accident for her opinion on the need for
reconstructive surgery. The plastic surgeon arrives at the ED, obtains a history of present illness including an extended
history of present illness; a system review, including constitutional, musculoskeletal, integumentary, neurologic, and
EENMT; and the patient’s social history and past medical history. The plastic surgeon then performs a physical exam
including respiratory, cardiovascular, and an extended examination of the skin and bony structures of the patient’s face.
The plastic surgeon performs moderate medical decision making, including deciding the patient needs major surgery to
repair the injuries. The plastic surgeon schedules the patient for surgery the next day and documents her full note with
findings in the ED chart.
A. 99284-57 B. 99244
C. 99243-57 D. 99221

28. At the request of the mother’s obstetrician, the physician was called to attend the birth of an infant being delivered
at 29 weeks gestation. During delivery, the neonate was pale and bradycardic. Suctioning and bag ventilation on this

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1000 gram neonate was performed with 100 percent oxygen. Brachycardia worsened; endotracheal intubation was
performed and insertion of an umbilical line for fluid resuscitation. Later this critically ill neonate was moved from the
delivery room and admitted to the NICU with severe respiratory distress and continued hypotension. What are the
appropriate procedure codes?
A. 99465, 99468 B. 99465, 99464, 99468-25, 31500, 36510-51
C. 99468, 99464 D. 99465, 99468-25, 31500-59, 36510-59

29. 38-year-old female initial visit, just moved from out of state, has neck and back pain for the last year and is getting
worse. Pain is exacerbated when she drives, bends, or changes positions, and moderately alleviated with ibuprofen.
Positive for aches and weakness in her muscles and tingling and numbness of the arms and hands, as well as headaches.
All other systems are reviewed and are negative. She has had a partial hysterectomy and is divorced. Her mother has a
history of breast cancer. The physician performs an exam on the following systems: constitutional, eyes, ENT,
respiratory, cardiovascular, gastrointestinal, musculoskeletal, and neurologic. X-rays of the cervical and lumbar spine
were taken. Will be sending her to get a MRI and to start physical therapy. Prescription was given for muscle relaxer.
Select the appropriate CPT® code for this visit?
A. 99202 B. 99203
C. 99214 D. 99244

30. four-year-old patient presents with pain in the left forearm following a fall from a chair. The injury occurred one
hour ago. Her mom applied ice to the injury but it does not appear to help. The ED physician performs a four system
ROS. The patient lives at home with both parents and attends pre-K classes. The patient has no known drug allergies.
The ED physician performs an extended six system exam. An X-ray is ordered, which shows a fracture of the distal end of
the radius as read by the radiologist. The ED physician performs moderate conscious sedation with ketamine for 30
minutes. The fracture is reduced and cast applied by an orthopedic surgeon following consultation with the ED
physician. The child was monitored with pulse oxymetry, cardiac monitor and frequent physician evaluation. The patient
was discharged with a sling and requested to follow up with the orthopedic surgeon. Code the services performed by
the ED physician.
A. 99284, 99143 B. 99284-25, 99155
C. 99283-25, 99151 D. 99283