E/M Code Case Study

Evaluation and Management

Append the Correct E/M Code(s)

(Multiple Choice)

1. An established patient is seen by the provider for a fever, cough, and wheezing. A comprehensive history, and detailed physical exam is performed; 500mg of amoxicillin and 10mgs of prednisone is prescribed. Based upon the medical decision making, what is the correct E/M code?

a.) 99204

b.) 99205

c.) 99214

d.) 99215

2. A European American male patient with a history of Lupus presents for a follow up visit. The patient diagnoses are Chronic Kidney Disease stage 4 and lupus erythematosus with an expanded problem focused history and exam. Which E/M code should be selected?

a.) 99203

b.) 99204

c.) 99202

d.) 99213

3. The patient made an appointment to discuss

A patient presents to an outpatient center to undergo a colonoscopy for possible polyp removal. By hot biopsy forceps, a polyp is removed from the descending colon, and by snare technique, a polyp is removed further up into the transverse colon. What CPT code(s) should be reported by the FACILITY?

a.) 45385, 45384-59

b.) 45384, 45385-51

c.) 45385

d.) 45384

14. For question #13 what code(s) should be reported for the SURGEON?

a.) 45385, 45384-59

b.) 45385, 45384-51

c.) 45385

d.)

A double osteotomy bunionectomy procedure is performed to correct severe hallux valgus of the left first metatarsal with 0.062 K wire fixation and application of cast.

a.) 28296-TA

b.) 28299-TA

c.) 28296-TA, 29425-TA

d.) 28299-LT

16. A 50-year-old female patient undergoes an Esophagogastroduodenoscopy with dilation of the esophagus over a guide wire at same operative episode.

a.) 43453, 43235-59

b.) 43226, 43235-59

c.) 43248

d.) 43456, 43235

17. A 31-year-old male patient developed an inclusion cyst on the left side of his next that required excision. The 6-cm cyst was located below the fascia involve an entire dissection of the tumor from the sub fascia; closure of deep fascia with 3-0 Vicryl; skin closed with 4-0 Maxon. Steri-strips were applied.

a.) 21556

b.) 11426, 12042-59

c.) 11426

d.) 21557

18. A 59-year-old female patient with thoracic vertebral fractures of the spine presents for a percutaneous vertebroplasty. A needle is inserted through the right pedicle of the T7 and T8 vertebral body defects and methyl methacrylate is injected. The procedure was done under fluoroscopic guidance. What codes are reported for the facility?

a.) 22305, 76013-TC

b.) 22325, 76012-TC

c.) 22305, 76012-TC

d.) 22520, 22522,