Evaluation and Management Coding Flashcards
7 cards from real COBGC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Evaluation and Management Coding flashcards as text
A patient two weeks post-cesarean presents with wound dehiscence requiring evaluation and debridement. To bill a separate E&M during the global period for this complication, the coder appends:
Answer: Modifier 24
Modifier 24 is appended to indicate the E&M service addresses an unrelated or complicated condition (wound dehiscence) during the global postoperative period.
Which preventive medicine code is used for a new female patient aged 40–64 presenting for her annual well-woman examination?
Answer: 99386
CPT 99386 covers comprehensive preventive medicine for a new patient aged 40–64; established patients in the same age range use 99396.
A gynecologist performs a colposcopy and, on the same day, provides a significant evaluation for new pelvic pain unrelated to the colposcopy indication. The E&M service should be reported with:
Answer: Modifier 25
Modifier 25 identifies a significant, separately identifiable E&M service provided on the same day as a minor procedure such as colposcopy.
A patient with a history of cervical cancer presents for routine surveillance. The physician reviews imaging showing no recurrence, manages hormone therapy, and counsels on late treatment effects. This visit most closely supports which MDM level?
Answer: Moderate complexity
Managing a known chronic illness (cancer surveillance), reviewing diagnostic data, and prescription drug management collectively support Moderate complexity MDM.
Under the 2021 MDM guidelines, which of the following falls under the 'Amount and/or Complexity of Data' element?
Answer: Reviewing external records and ordering or reviewing diagnostic tests
The data element encompasses ordering/reviewing tests, reviewing external records, and independent interpretation of results—not medication lists or vital signs.
A patient with abnormal uterine bleeding has outside pathology slides independently reviewed, a pelvic ultrasound ordered, and a discussion of medical versus surgical management options. Under 2021 MDM, the data complexity most likely supports:
Answer: Moderate data
Reviewing an outside independent interpretation (pathology) and ordering a diagnostic test together satisfy multiple Moderate-level data criteria.
Which of the following is NOT a recognized component of the 'Risk of Complications and/or Morbidity or Mortality' element in 2021 MDM?
Answer: Documenting the patient's blood pressure reading
Documenting vital signs such as blood pressure is a clinical task but is not a risk factor element within MDM; recognized risk elements include drug management, surgical risk, and social determinants affecting treatment.