COBGC Evaluation and Management Coding 1

Question 1

What are the key components of E/M coding for OB/GYN visits?

Accepted Answer

History, examination, and medical decision-making complexity

Answer

E/M code selection is based on the extent of history taken, examination performed, and complexity of medical decision-making.

Question 2

How is time-based E/M coding used in OB/GYN?

Accepted Answer

When counseling or coordination of care dominates the visit, total time determines the code level

Answer

When more than 50% of the visit involves counseling/coordination, time can determine the E/M level instead of the three key components.

Question 3

What is the difference between new and established patient E/M codes?

Accepted Answer

New patients have not been seen by the practice within 3 years; established patients have

Answer

New patient codes (99201-99205) have higher values than established patient codes (99211-99215) because they require more comprehensive evaluation.

Question 4

What documentation supports medical necessity for E/M services?

Accepted Answer

Chief complaint, history of present illness, review of systems, and clinical findings supporting the diagnosis

Answer

Thorough documentation of the clinical encounter supports the medical necessity of the service level billed.

Question 5

How are preventive visit codes used in gynecology?

Accepted Answer

For annual well-woman exams including breast and pelvic examinations, separate from problem-oriented visits

Answer

Preventive visit codes cover routine wellness exams; if a problem is also addressed, a separate E/M code with modifier 25 may be added.

(COBGC) Certified Obstetrics Gynecology Coder Practice Test