1. Mrs. Smith was seen by her family physician, Dr. Marks. Mrs.

Smith complains she has had a sore

throat, breathing problems, and a fever for five days. She is a diabetic patient and has been taking over-
the-counter medications that have interfered with her insulin medication. Dr. Marks spent 50 minutes
with the patient during the examination. How should the physician report this service?

A) 99215 B) 99204 C) 99205 D) 99214

2. Dr. Gavin, a pediatrician, continues to follow Baby Girl Laura, who is not critically ill but requires
intensive observation for lung function and respiratory and oxygen monitoring. Laura is 14 days old
with a current weight of 1,200 grams. Dr. Gavin initially provided care on Monday. He continued to see
her on Tuesday and Wednesday. How should Dr. Gavin report all three days of care?

A) 99468 x 3 B) 99460, 99479 x 2

C) 99477 x 3 D) 99477, 99478 x 2

3. Bill, a retired U.S. Air Force pilot, was on observation status 12 hours to assess the outcome of a fall
from the back of a pickup truck into a gravel pit. The physician discharged Bill from observation that
same day after determining that no further monitoring of his condition was necessary. The physician
provided the medical decision making was of a low complexity.

A. 99221, Z04.9, W18.30XA B. 99234, Z04.3, W17.2XXA

C. 99238, Z04.3, W18.30XA D. 99234, 99238, Z04.3, W17.2XXA

99238 will not be coded because the discharge time is not given in the chart

4. Dr. Martin admits a 65-year-old patient to the hospital with acute pericarditis following a severe viral
infection. The patient has complained of retrosternal, sharp, intermittent pain of 2 days' duration that is
reduced by sitting up and leaning forward, accompanied by tachypnea. The physician ordered an
electrocardiogram, x-rays, and routine laboratory workup. The physician considers the multiple
diagnoses of pericarditis following infection, unstable angina, dissecting aneurysm, pulmonary infarction,
or esophageal disease, indicating a Moderate level of medical decision making complexity also spent
80mints face to face with the patient, please suggest the code ?

A. 99223, 99418, R07.2, R06.82 B. 99223, I30.0, I20.0, I72.9, I26.99, K22.9

C. 99245, I30.0, I20.0, I72.9, I26.99, K22.9 D. 99223, R07.2, R06.82

Need assistance with ICD codes option B and D
5. A gynecologist admits an established patient, a 35-year-old female with dysfunctional uterine –
bleeding (DUB), after seeing her in the clinic that day. During the course of the comprehensive history,
the physician notes that the patient has a history of irregular periods of heavy flow. She has had
irregular heavy periods and intermittent spotting for 4 years. The patient has been on a 3-month course
of oral contraceptives (OCP). The family history is positive for endometrial cancer, with mother, two
aunts, and two sisters who had endometrial cancer. The patient has a personal history of cervical and
endometrial polyp removal 3 years prior to admission, the physician notes the patient has a large
amount of blood in the vault and an enlarged uterus. The prolonged hemorrhaging has resulted in a
very thin and friable endometrial lining. The physician orders the patient to be started on intravenous
Premarin and orders a full laboratory workup. The medical decision making is of High complexity and
also spent 55 minutes face to face with patient please suggest the code ?

A. 99223, N91.5, Z80.49 B. 99222, N92.1, Z87.42, Z80.49

C. 99215, 99222, N89.8, Z87.42, Z80.49 D. 99222, N91.5, Z80.49

6. Dr. Black admits a patient with an 8-day history of a low-grade fever, tachycardia, tachypnea, and
basal consolidation of the lung and limited pleural effusion on the left side. An extensive past, family,
and social history is taken as part of a comprehensive history. Bowel sounds are feeble. The pulse
is rapid and thread.

There is a bluish discoloration of the flanks. The physician orders laboratory tests and radiographic
studies, including an abdominal sonogram as he considers the extensive diagnostic options and
the medical decision making complexity is high for this patient.

A. 99233, R50.9, R00.0, R06.82, J13, J91.8, R19.15

B. 99233, R50.9, I47.1, R06.82, J18.9, J91.8

C. 99223, R50.9, R00.0, R06.82, J13

D. 99223, R50.9, R00.0, R06.82, J13, J91.8, R19.15

7. Dr. Stephanopolis makes subsequent hospital visits to Salanda Ortez, who has been in the hospital
for primary viral pneumonia. She was experiencing severe dyspnea, rales, fever, muscle aches, and
chest pain. The chest radiography showed patchy bilateral infiltrates and basilar streaking. Sputum
microbiology was positive for a secondary bacterial pneumonia. The physician conducted an interval
history focused on the patient's current problems and continued to do a problem-focused physical
examination. The medical decision making was straightforward, and the patient was given intravenous
antibiotic to address the bacterial pneumonia also spent 50 minutes face to face with patient.

A. 99231, R06.00, R09.89, R50.9, M79.1, R07.9, R91.8, R89.9 B. 99231, J15.8

C. 99233 J15.8 D. 99232, J15.8

8.A 57-year-old male was sent by his family physician to a urologist for an office consultation. The
patient has had bright red blood in his urine sporadically for the past The urologist recommends a
cystoscopy to be scheduled for the following week and discusses the procedure and risks with the
patient. The medical decision making is of moderate complexity. Report only the office service.

A. 99243-25 B. 99244-57, 52000 C. 99253-25, 52000 D. 99244-25

9. A neurological consultation in the emergency department of the local hospital is requested for a 25-
year-old male with suspected closed head trauma. The patient had a loss of consciousness (LOC) this
morning after receiving a blow to the head in a high school basketball game. He presents to the
emergency department with a headache, dizziness, and confusion. During the comprehensive history,
the girlfriend relates that the patient has been very irritable and confused since the incident. Physical
examination reveals the patient to be unsteady and exhibit difficulty in concentration when stating
months in reverse. The pupils dilate unequally.The neurologist orders a stat CT and MRI. The physician
suspects a subdural hematoma or an epidural hematoma, and the medical decision making complexity is
high and also spent 90 minutes with face to face with patient.

A. 99285 B. 99245,99417 C. 99245 D. 99245,99417*2

10. An obstetrician is requested to provide an office consultation to a 23-year-old female with first-
trimester bleeding. The patient presents with a history of brownish discharge and occasional pinkish
discharge. During the comprehensive history, the patient relates that she has had suprapubic pain in
the
past week and cramping. She has felt nausea and has vomited on three occasions. On one occasion, the
nausea was accompanied by dizziness and vertigo.. The uterus is found to be soft and involute. There is
cervical motion tenderness and significant abdominal tenderness on palpation. A left pelvic mass is
palpated in the left quadrant. The physician orders a pelvic ultrasound, a complete CBC, and differential.
Considering the range of possible diagnoses, the medical decision-making complexity is high.

A. 99255 B. 99242 C. 99245 D. 99235

11. A 56-year-old established male patient presents to his family physician for a checkup at the local
outpatient clinic. The physician conducts a detailed history and physical examination, and the
checkup takes 45 minutes.

A. 99214 B. 99403 C. 99386 D. 99396

12. Karra Hendricks, a 37-year-old female, is an established patient who presents to the office with pain
in the RLQ with fever. the medical decision making is noted to be of a low complexity but provider
spent 75 minutes at this visit.

A. 99214 B. 99215, 99417*3 C. 99215 D. 99215, 99417*2

13. Sam, a 4-year-old male, was brought to the emergency department by his mother, where Dr. Black,
the emergency department physician, examined the child. Dr. Black has not provided service to this
child in the past. mother stated that the child has had a temperature of 101º F for the past 24 hours,
has been very fussy, and has been pulling on his left ear. diagnosed otitis media, for which he prescribed
a 10-day course of amoxicillin.
A. 99283 B. 99213 C. 99214 D. 99284
 14. Dr. Robertson provided the first month of care planning oversight for home care of a 64-year-old
male patient with advanced pancreatic cancer. He developed a plan that included home oxygen,
intravenous diuretics, and pain control management by means of intravenous morphine. The time spent
in the low-intensity oversight for the month was 45 minutes
A. 99378 B. 99374 C. 99375 D. 99380

15. The patient is a 35-year-old male who presents to the emergency department (ED) after several
hours of low back pain, nausea, and chills. A urinalysis lab and CT of the abdomen is ordered. The
results of the CT show two small kidney stones. The ED physician discusses the results with the patient
and tells him the stones are small and will pass on their own. Medical decision making (MDM) of
moderate complexity is made with the patient being discharged, with a prescription of pain medication,
and with a diagnosis of kidney stones. Select the E/M code and diagnosis code(s).

A. 99285, N20.0, M54.5, R11.2, R68.83 B. 99284, M54.5, R11.2, R68.83, N20.0

C. 99283, N20.0 D. 99284, N20.0

16. A 63-year-old man wants a second opinion for his sleep apnea. He decides to go to another physician.
The physician documents a detailed history. He has had it for the past five months. Sleep is disrupted by
frequent awakenings and getting worse due to anxiety and snoring. Current medication that he is on
now is not helping him. Moderate MDM. And spent 65 minutes What CPT® code should be reported?
A. 99205 B. 99204 C. 99215 D. 99214

The pt is new to the different physician

18. Physician performs a medical review and documentation on an 83-year-old patient who has been in
the hospital for the last two days with confusion. Problem focused exam where she is alert and oriented
x 3 today. Low medical decision making by ordering an echocardiogram and to continue IV fluids. Patient
is not safe to return home. What CPT® code should be reported for this visit?
A. 99231 B. 99221 C. 99224 D.
99234
Pt is already In hospital for the last 2 days and the visit is subsequent

19. 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 that may need surgery. Patient was in an
automobile accident and an opinion is needed for reconstructive surgery. The plastic surgeon arrives at
the ED, obtains detailed history and performs a detailed exam. The plastic surgeon performs a
moderate medical decision making, in deciding that 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. The E/M service reported by the plastic surgeon is:
A. 99284-57 B. 99243-32 C. 99243-57 D.
99284-32

Need assistance why low MDM is taken in consultation service

 20. At the request of the mother’s obstetrician, a neonatologist is called to attend the birth of an infant
being delivered at 29 weeks gestation. During delivery, the neonate was pale and bradycardic needing
resuscitation. Neonatologist performs the suctioning and bag ventilation on this 1000 gram neonate
was performed with 100 percent oxygen. Brachycardia worsened, requiring endotracheal intubation
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 reported by the neonatologist?

A. 99465, 99468 B. 99465, 99464, 99468-25, 31500-59, 36510-59

C. 99468, 99464 D. 99465, 99468-25, 31500-59, 36510-59

21. A 15-year-old male is seen by the pediatrician in his office for having excessive thirst and frequent
urination. A urine dip is performed showing +3 sugar and with some ketones. Glucometer reading is
done showing a blood sugar range of 500-600. Physician sends the patient with his father to the
hospital for emergency admission and insulin drip. The pediatrician meets the patient at the hospital
and high complexity medical decision making. How should the pediatrician code the E/M service for this
visit?
A. 99214 B. 99221 C. 99223 D.
99285
In the question Emergency admission is mentioned and not the emergency dept.

22. A 62-year-old female returns to a family practice having shortness of breath, nausea and diaphoresis. It
has been two years since her last visit to the practice. An EKG, chest X-ray and labs are ordered. The
physician also orders to have her records sent from her cardiologist. The medical decision making is high.
The patient is diagnosed with exacerbation of congestive heart failure. What is the correct evaluation
and management service for this encounter?

A. 99205 B. 99215 C. 99204 D.

99214

23. This morning a 48-year-old is placed in observation status from the emergency room with severe
diarrhea and extreme thirst. patient is suffering from dehydration. The physician places the patient on
IV saline 500 ml and conducts normal saline hydration for a couple hours. The medical making decision
making is of moderate complexity. Patient is discharged home in the late evening on the same day and
is told to return if symptoms occur again. The E/M service(s) for this encounter is:
A. 99285 B. 99222, 99238 C. 99235 D. 99238