CPC Evaluation and Management (E/M) 2

Question 1

A physician documents a detailed history, detailed examination, and medical decision making of moderate complexity for an established office patient. Which E/M code level is most appropriate?

Accepted Answer

99214

Answer

99214 requires at least 2 of 3 key components at the detailed/moderate complexity level for an established patient.

Question 2

Under the 2021 E/M guidelines for office visits, what primarily drives code selection for established patients?

Accepted Answer

Medical decision making or total time

Answer

The 2021 AMA guidelines base office/outpatient E/M level selection on either MDM or total time on the date of the encounter.

Question 3

Which element is NOT part of Medical Decision Making (MDM) in the 2021 E/M framework?

Accepted Answer

Number of organ systems examined

Answer

MDM consists of three elements: problems, data, and risk — physical examination organ systems are not part of MDM.

Question 4

A physician spends 45 minutes of total time on the date of service with a new patient. Which office E/M code is reported?

Accepted Answer

99204

Answer

99204 covers 45–59 minutes of total time for a new patient office visit under 2021 guidelines.

Question 5

What does the term 'total time' mean in the context of 2021 office E/M coding?

Accepted Answer

Time spent on all work related to the encounter on that calendar date

Answer

Total time includes all physician work on the date of service — pre-visit review, face-to-face time, and post-visit documentation.

(CPC) Certified Professional Coder Practice Test

(CPC) Certified Professional Coder Practice Test

CPC Evaluation and Management (E/M) 2