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medical coding questions and answers
Typology: Assignments
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ray. After reviewing the x-ray, Dr. Crampon admitted Adam to the hospital for treatment of pneumonia. After his regular office hours, Dr. Crampon visited Adam in the hospital where he dictated a comprehensive history, comprehensive examination, and decision-making of moderate complexity. How would you report Dr. Crampon’s services? a. 99214 b. 99222 c. 99204, 99222- d. 99223, 99214-
back with an abnormal reading and is worried since her aunt had passed away with cervical cancer. The physician spends an extra 45 minutes face-to-face time discussing with her the awareness, other screening procedures and treatment if it turns out to be cervical cancer. What code(s) should be used for this visit? A. 99215 B. 99213, 99354 C. 99213 D. 99213, 99403
ER physician documents a total time of 30 minutes on this critical infant in which the physician already subtracted the time for the other billable services. Select the E/M service and procedures to report for the ER physician? A. 99291-25, 36555, 31500 B. 99291, 36556, 31500, 82803 C. 99285-25, 36556, 31500, 8280 3 D. 99475, 36556
physician. The child was monitored with pulse oxymetry, cardiac monitor and frequent physician evaluation. The patient was discharged with a sling and requested to follow up with the orthopedic surgeon. Code the services performed by the ED physician. A. 99284, 99143 B. 99284-25, 99148 C. 99283-25, 99143 D. 99283
1 0. “b” This is a new patient visit not a consultation. “A “consultation” initiated by a patient and/or family, and not requested by a physician or other appropriate source, …is not reported using the consultation codes but may be reporting using the office visit, home service, or domiciliary/rest home care codes.” Report a consultation code only when a request (written or verbal) is made by another physician or appropriate source, an opinion is rendered, and a written report is sent back to the “requestor.” In this case the patient initiated the visit.
1 1. “a” You can find this definition in the CPT Professional Edition under the subcategory guidelines for Emergency Department Services.
1 2. “d” Preventive medicine services are based on new vs. established patient and age.
B Scenario documents patient returning to the gynecologist guiding you to the codes for established patient office visit. This eliminates multiple choices A and C. For this scenario, the patient did not have any complaints that required the presence of a physician. There was no examination or medical making decision performed for the patient guiding you to code 99211. There must be an order for the patient to come in for the office visit. For the diagnosis code, the pessary was removed for cleaning with no documentation of a complication of the device nor is this device a contraceptive device; therefore, report V52.8 (Fitting, device, prosthetic, other specified)
C According to CPT® guidelines: When the patient is admitted to the hospital as an inpatient in the course of an encounter in another site of service (example, hospital emergency department, observation status in a hospital, physician’s office, nursing facility) all evaluation and management services provided by that physician in conjunction with that admission are considered part of the initial hospital care when
components: Problem Focused History + Expanded Problem Focused Exam + Straightforward MDM = 99212
Two out of three key components are required. The provider performs a detailed exam and moderate MDM. 99214 is the correct code. After the evaluation the patient needs the physician to address questions and concerns he has regarding the liver transplant surgery. According to CPT® guidelines: 99354-99355 are used to report the total duration of face-to-face time spent by a physician beyond the usual service in either the inpatient or outpatient setting. The prolonged service includes the time he spent in face-to-face contact with the patient when he was not performing the history, physical examination, and medical decision making related to the level of E/M service he reported. In the CPT® index, look up Prolonged Services. You are referred 99354-99357, 99360. 99354 is the correct code since 30 minutes was spent face-to-face.