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

The 2021 E/M guidelines allow office/outpatient E/M code selection based on either medical decision making (MDM) or total time spent on the date of the encounter.

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

MDM is assessed by evaluating the number/complexity of problems addressed, the amount/complexity of data reviewed, and the risk of complications and/or morbidity or mortality.

Question 3

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

Accepted Answer

99204

Answer

CPT 99204 represents a new patient office or outpatient visit with moderate complexity medical decision making.

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

A new patient is one who has not received any professional services from the same physician or physician of the same specialty in the same group practice within the past 3 years.

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

Under 2021 guidelines, total time for office E/M includes all physician/QHP time on the date of encounter: preparing, face-to-face, and post-visit documentation.

COC - Certified Outpatient Coder Practice Test

COC - Certified Outpatient Coder Practice Test

COC Evaluation and Management Coding