Evaluation and Management Coding Flashcards

An established patient is seen for management of two stable chronic illnesses and one acute, uncomplicated illness. The provider performs a medically appropriate history and examination. According to the 2024 E/M guidelines, which element of Medical Decision Making (MDM) does this encounter meet?

Answer: Moderate Number and Complexity of Problems Addressed

According to the AMA CPT® E/M guidelines, Moderate Complexity for the 'Number and Complexity of Problems Addressed' element includes '1 or more chronic illnesses with exacerbation, progression, or side effects of treatment; or 2 or more stable chronic illnesses; or 1 undiagnosed new problem with uncertain prognosis; or 1 acute illness with systemic symptoms; or 1 acute, complicated injury.' This scenario, with two stable chronic illnesses, meets the criteria for Moderate complexity.

A physician performs an office consultation for a new patient and spends a total of 75 minutes on the date of the encounter. The time for a level 5 new patient office visit (99205) is 60 minutes. Which CPT® code(s) should be reported for this service?

Answer: 99205, 99417

CPT® code 99205 is appropriate for the base service as the time (75 minutes) exceeds the 60-minute threshold. CPT® add-on code +99417 is used to report prolonged office or other outpatient E/M services. It is used for each additional 15 minutes of total time spent on the date of the encounter beyond the minimum time required for the highest-level service (99205). Since the physician spent 15 minutes beyond the 60-minute threshold for 99205, reporting 99417 once is correct.

When selecting an E/M service level based on Medical Decision Making (MDM), which of the following is NOT one of the three core elements?

Answer: Complexity of the Medically Appropriate History and/or Examination

The current E/M guidelines, updated in recent years, base the level of MDM on three elements: 1) Number and Complexity of Problems Addressed, 2) Amount and/or Complexity of Data to be Reviewed and Analyzed, and 3) Risk of Complications and/or Morbidity or Mortality of Patient Management. While a medically appropriate history and examination are required, their complexity is no longer a key element in selecting the E/M code level.

An established patient presents to the office with a sore throat and fever. The physician diagnoses acute pharyngitis. The management decision involves prescribing an antibiotic. What is the level of risk associated with this patient management decision?

Answer: Low

The AMA's MDM table defines 'prescription drug management' as an example of moderate risk. However, the overall clinical scenario must be considered. An acute, uncomplicated illness like pharyngitis treated with a common antibiotic is typically considered Low Risk of morbidity from additional diagnostic testing or treatment. Moderate risk involves more significant considerations like managing a chronic illness with prescription drugs or decisions about minor surgery.

Which of the following activities can be included when calculating the total time for selecting an E/M code?

Answer: Reviewing test results and preparing for the patient's visit on the same day

Total time for E/M coding includes both face-to-face and non-face-to-face time spent by the physician or other qualified health care professional on the day of the encounter. This includes activities like preparing to see the patient (e.g., reviewing tests), obtaining history, performing the exam, counseling, ordering medications or tests, and documenting in the health record. Time spent by clinical staff is not included.

For the purpose of MDM, which of the following constitutes an 'independent historian'?

Answer: A parent providing a history for a young child

An independent historian is an individual (e.g., parent, guardian, surrogate, spouse, witness) who provides a history in addition to a history provided by the patient, or when the patient is unable to provide a complete or reliable history. A young child is often unable to provide a complete history, making the parent's input qualify under this definition. The patient's own record is not an 'independent historian'.