Evaluation and Management Coding Flashcards

A surgeon sees a patient in the office 10 days after an appendectomy. This visit is within the global period. How should this visit be coded?

Answer: No separate code — the visit is included in the global surgical package

Routine follow-up visits within the global surgical period are included in the surgical package and are not coded separately.

Which E/M code is used when a physician provides transitional care management services with moderate medical complexity, with a face-to-face visit occurring within 14 days of discharge?

Answer: 99495

99495 covers transitional care management with moderate medical complexity when the required face-to-face visit occurs within 14 days of discharge.

A physician documents a chief complaint, history of present illness (4 elements), review of 2 organ systems, and no past/family/social history. What level of history is documented?

Answer: Expanded problem focused

An expanded problem focused history includes brief HPI (1-3 elements) or extended, problem pertinent ROS (1-2 systems), and no PFSH — but extended HPI with 2-system ROS also meets expanded problem focused.

Which of the following is NOT a recognized setting for E/M services coded with office visit codes (99202–99215)?

Answer: Hospital inpatient room

Hospital inpatient services use inpatient hospital care codes (99221–99223 initial, 99231–99233 subsequent), not office visit codes.

A physician provides care and coordination for a patient with two or more chronic conditions via chronic care management. The physician spends 25 minutes in a calendar month. Which code is reported?

Answer: 99490

99490 is reported for the first 20 minutes of clinical staff time for CCM services in a calendar month for patients with 2+ chronic conditions.

When coding an inpatient admission on the same day as an outpatient E/M visit at the same facility, how should the services be reported?

Answer: Report only the initial hospital care code (99221–99223), incorporating all services from that date

When a patient is admitted the same day as an outpatient visit, all services are combined and only the initial inpatient code is reported.

A physician performs a 60-minute online digital E/M visit (patient-initiated) through a secure portal for an established patient. Which code is most appropriate?

Answer: 99423

99423 covers online digital E/M services for established patients requiring 21 or more minutes of cumulative physician/QHP time.