CPC Evaluation and Management (E/M) 2 — Questions and Answers
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?
- 99213
- 99214 (Correct answer)
- 99215
- 99212
Correct answer: 99214
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?
- Number of body systems examined
- Medical decision making or total time (Correct answer)
- Chief complaint complexity
- Number of diagnoses reviewed
Correct answer: Medical decision making or total time
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?
- Number and complexity of problems addressed
- Amount and complexity of data reviewed
- Risk of complications and morbidity
- Number of organ systems examined (Correct answer)
Correct answer: Number of organ systems examined
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?
- 99203
- 99204 (Correct answer)
- 99205
- 99202
Correct answer: 99204
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?
- Time spent face-to-face with the patient only
- Time spent on all work related to the encounter on that calendar date (Correct answer)
- Time documenting in the EHR after the visit
- Time from check-in to check-out
Correct answer: Time spent on all work related to the encounter on that calendar date
Total time includes all physician work on the date of service — pre-visit review, face-to-face time, and post-visit documentation.
Question 6: A patient presents with three chronic conditions, each requiring ongoing management. Under 2021 MDM guidelines, how are these classified for the 'problems' element?
- One chronic condition with exacerbation
- Multiple chronic illnesses — supports high complexity (Correct answer)
- Acute uncomplicated illness
- Stable chronic illness — supports low complexity
Correct answer: Multiple chronic illnesses — supports high complexity
Multiple chronic conditions each requiring management meets the threshold for high complexity in the problems element of MDM.
Question 7: Which of the following services may be reported separately on the same day as an E/M visit?
- Routine EKG interpretation included in the visit
- A separately identifiable surgical procedure with modifier 25 on the E/M (Correct answer)
- Nurse's vital signs documentation
- Patient education covered in counseling time
Correct answer: A separately identifiable surgical procedure with modifier 25 on the E/M
A significant, separately identifiable E/M service on the same day as a procedure may be billed with modifier 25 appended to the E/M code.
CPC Evaluation and Management (E/M) 2
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?