COC Evaluation and Management Coding

Question 1

Under the 2021 AMA E/M guidelines, which two methods may be used to select an office/outpatient E/M level?

Accepted Answer

Medical decision making or total time

Answer

History, exam, and medical decision making

Answer

History and time

Answer

Presenting problem and chief complaint

Question 2

What are the three elements of Medical Decision Making (MDM) in E/M coding?

Accepted Answer

Number/complexity of problems, amount/complexity of data, risk of complications

Answer

Chief complaint, HPI, ROS

Answer

History, physical exam, diagnosis

Answer

Time, complexity, coordination of care

Question 3

Which E/M code is used for a new patient office visit of moderate complexity?

Accepted Answer

99204

Answer

99213

Answer

99203

Answer

99214

Question 4

For outpatient E/M coding, a 'new patient' is defined as one who:

Accepted Answer

Has not received professional services from the physician or same group in the past 3 years

Answer

Has not been seen in any healthcare setting in the past year

Answer

Is visiting the practice for the first time ever

Answer

Has a new diagnosis not previously treated

Question 5

When using total time to select an E/M level, what does 'total time' include?

Accepted Answer

All time on the date of encounter, including pre/post-visit activities

Answer

Only face-to-face time with the patient

Answer

Time spent in the examination room only

Answer

Documentation time only

Question 6

Which E/M code is reported for an established patient seen in the emergency department with a high-severity problem?

Accepted Answer

99285

Answer

99215

Answer

99284

Answer

99222