Scenario-Based Questions and Answers

1. Scenario: A patient is admitted with severe pneumonia and requires a detailed history, a
comprehensive exam, and high-complexity medical decision-making. What initial hospital care
E/M code would you select, and why?

Patient Name: Elizabeth Johnson

Age: 68
Gender: Female
Date of Admission: 06/24/2024

Chief Complaint:

Severe shortness of breath, productive cough, and high fever.

History of Present Illness (HPI):

Elizabeth Johnson, a 68-year-old female, presents with a 5-day history of progressively

worsening shortness of breath, high fever reaching 103°F, and a productive cough with green
sputum. She has felt weak and fatigued, unable to perform her daily activities. Her symptoms
have not improved with over-the-counter medications, and she reports mild chest discomfort
when coughing.

Past Medical History (PMH):

 Chronic obstructive pulmonary disease (COPD)

 Hypertension
 Type 2 diabetes mellitus

Past Surgical History (PSH):

 Hysterectomy at age 45
 Cholecystectomy at age 60

Social History:

 Former smoker (30 pack-years, quit 5 years ago)

 No alcohol or drug use
 Lives alone, independent in activities of daily living

Family History:

 Mother had a history of stroke.

  Father had coronary artery disease.

Review of Systems (ROS):

 General: Fever, fatigue, weight loss.

 Respiratory: Severe shortness of breath, productive cough, chest discomfort.
 Cardiovascular: No chest pain or palpitations outside of coughing.
 Gastrointestinal: No nausea, vomiting, or diarrhea.
 Genitourinary: No dysuria or hematuria.
 Neurological: No dizziness, syncope, or focal neurological deficits.

Physical Examination:

 Vital Signs: BP 145/88, HR 110 bpm, RR 28, Temp 102.5°F, SpO2 88% on room air.
 General: Appears ill and in respiratory distress.
 HEENT: Oropharynx dry, no lymphadenopathy.
 Cardiovascular: Tachycardic, regular rhythm, no murmurs.
 Respiratory: Use of accessory muscles, crackles and rhonchi bilaterally.
 Abdomen: Soft, non-tender, no hepatosplenomegaly.
 Neurological: Alert and oriented, no focal deficits.
 Extremities: No cyanosis or edema.

Diagnostic Tests:

 CBC: Elevated WBC count.

 CMP: Elevated glucose, stable electrolytes.
 Chest X-ray: Bilateral lower lobe infiltrates suggestive of pneumonia.
 Blood cultures: Pending.
 Sputum culture: Pending.
 ABG: Hypoxemia with a PaO2 of 55 mmHg on room air.

Assessment:

1. Severe community-acquired pneumonia.

2. Acute exacerbation of COPD.
3. Hypertension.
4. Type 2 diabetes mellitus.

Plan:

 Admission: Admit to the ICU for close monitoring due to respiratory distress and hypoxemia.
 Antibiotics: Initiate broad-spectrum antibiotics (Ceftriaxone and Azithromycin).
 Respiratory support: Start on supplemental oxygen, consider non-invasive ventilation (BiPAP) if
no improvement.
 Fluids: Administer IV fluids for hydration.
 Diabetes management: Initiate insulin therapy to manage hyperglycemia.
 Monitoring: Frequent vital signs and continuous pulse oximetry.
  Consultations: Pulmonology and infectious disease consults.

o Answer: I would select the highest level of initial hospital care E/M code, which is 99223.
This is because the patient's condition requires a comprehensive history, a
comprehensive examination, and high-complexity medical decision-making. These
elements meet the criteria for 99223, which includes an extensive workup and
management plan for a serious illness.
o

2. Scenario: A patient with diabetes and hypertension is admitted for chest pain. During the
hospital stay, the provider conducts a detailed history, a detailed exam, and moderate-
complexity medical decision-making. How would you code the initial hospital visit?
o Answer: For this initial hospital visit, I would select code 99222. This code is appropriate
because it includes a detailed history, a detailed examination, and moderate-complexity
medical decision-making. The documentation supports these components, which are
necessary for managing the patient's multiple chronic conditions and evaluating the
chest pain.

Patient Name: David Brown

Age: 55
Gender: Male
Date of Admission: 06/24/2024

Chief Complaint:

Chest pain and shortness of breath.

History of Present Illness (HPI):

David Brown, a 55-year-old male with a history of diabetes and hypertension, presents with a 1-
day history of chest pain. The pain started suddenly while he was at rest, described as a pressure-
like sensation in the middle of his chest, radiating to his left arm and neck. The pain is rated 7/10
in intensity, accompanied by shortness of breath, sweating, and nausea. He denies any recent
physical exertion or trauma. Over-the-counter antacids provided no relief.

Past Medical History (PMH):

 Type 2 diabetes mellitus, poorly controlled with HbA1c of 9.0%.

 Hypertension, on medication but recently elevated readings.

Past Surgical History (PSH):

 None.
Social History:

 Smoker (10 pack-years, quit 10 years ago).

 Social alcohol use.
 Works as a software engineer.

Family History:

 Father had a myocardial infarction at age 60.

 Mother has type 2 diabetes.

Review of Systems (ROS):

 General: Feels fatigued, no recent weight loss.

 Cardiovascular: Positive for chest pain and palpitations.
 Respiratory: Shortness of breath, no cough or wheezing.
 Gastrointestinal: Nausea, no vomiting or abdominal pain.
 Genitourinary: No dysuria or hematuria.
 Neurological: No dizziness or syncope.

Physical Examination:

 Vital Signs: BP 160/95, HR 100 bpm, RR 22, Temp 98.4°F, SpO2 95% on room air.
 General: Appears anxious and mildly distressed.
 HEENT: No JVD, normal oropharynx.
 Cardiovascular: Tachycardic, regular rhythm, no murmurs.
 Respiratory: Clear to auscultation bilaterally.
 Abdomen: Soft, non-tender, no masses.
 Neurological: Alert and oriented, no focal deficits.
 Extremities: No edema, normal peripheral pulses.

Diagnostic Tests:

 EKG: Normal sinus rhythm with no acute ischemic changes.

 Troponin: Elevated, suggestive of cardiac injury.
 Chest X-ray: No acute findings.
 CBC: Mild leukocytosis.
 BMP: Elevated glucose, otherwise normal electrolytes.

Assessment:

1. Chest pain, likely non-ST-elevation myocardial infarction (NSTEMI).

2. Type 2 diabetes mellitus with poor control.
3. Hypertension.
Plan:

 Admission: Admit to telemetry for continuous cardiac monitoring.

 Cardiac Care: Start on antiplatelet therapy (Aspirin) and beta-blocker.
 Diabetes Management: Adjust insulin regimen and monitor blood glucose levels closely.
 Hypertension Management: Continue current antihypertensive medications and re-evaluate
after stabilization.
 Consultations: Cardiology consult for further evaluation and management.
 Follow-up: Repeat troponins and EKGs, daily review of clinical status and labs.

3.

4. Scenario: During a subsequent hospital visit, a patient with chronic obstructive pulmonary
disease (COPD) and a new diagnosis of pneumonia is seen. The provider conducts a problem-
focused history and examination, with low-complexity medical decision-making. Which code
should be used?
o Answer: In this scenario, I would use code 99231 for the subsequent hospital visit. This
code is appropriate for a problem-focused history and examination with low-complexity
medical decision-making. The documentation reflects the ongoing management of COPD
and the new pneumonia diagnosis without significant changes to the treatment plan.

5. Scenario: A postoperative patient develops an infection at the surgical site and has a follow-up
visit in the hospital. The provider performs an expanded problem-focused history and
examination, with moderate-complexity medical decision-making. Which subsequent hospital
care code would you select?
o Answer: For this follow-up visit, I would select code 99232. This code fits an expanded
problem-focused history and examination along with moderate-complexity medical
decision-making. The patient's postoperative infection requires careful management and
potential adjustments to the treatment plan, justifying this level of service.

6. Scenario: A patient with heart failure is admitted, and the initial visit includes a
comprehensive history, a comprehensive exam, and high-complexity medical decision-making.
The next day, the patient is seen again with worsening symptoms, requiring another
comprehensive history, comprehensive exam, and high-complexity decision-making. How
would you code these visits?
o Answer: For the initial visit, I would use code 99223, which covers a comprehensive
history and examination with high-complexity medical decision-making. For the
subsequent visit with the same level of care, I would use code 99233. Although it is rare
for a subsequent visit to require a comprehensive history and exam, the worsening
symptoms and high-complexity decision-making justify the highest subsequent hospital
care code.

7. Scenario: A patient is admitted with a urinary tract infection (UTI) and mild dehydration. The
provider performs a detailed history, detailed exam, and low-complexity medical decision-
making. What initial hospital care E/M code should be used?
o Answer: For this initial hospital care visit, I would select code 99221. This code is
appropriate for a detailed history and examination with low-complexity medical
 decision-making. The patient's conditions are relatively straightforward, and the
documentation supports this level of service.

8. Scenario: A patient with multiple chronic conditions including diabetes, hypertension, and
chronic kidney disease is admitted with acute renal failure. The provider takes a
comprehensive history, performs a comprehensive examination, and engages in high-
complexity medical decision-making. What E/M code is appropriate for the initial hospital
visit?
o Answer: The appropriate code for this initial hospital visit is 99223. This code includes a
comprehensive history and examination along with high-complexity medical decision-
making, which is necessary given the patient's multiple chronic conditions and acute
renal failure.

9. Scenario: A patient is admitted with acute gastrointestinal bleeding. On a subsequent hospital

visit, the provider performs an expanded problem-focused history and examination, with
moderate-complexity medical decision-making. What code would you select?
o Answer: I would select code 99232 for this subsequent hospital visit. The expanded
problem-focused history and examination, along with moderate-complexity medical
decision-making, are consistent with the requirements for this code, reflecting the
ongoing management of the acute gastrointestinal bleeding.

1. Scenario: A patient undergoes an open appendectomy due to acute appendicitis. The

operative report indicates that the appendix was inflamed but not ruptured. Which CPT code
would you use?
o Answer: For an open appendectomy due to acute appendicitis without rupture, the
appropriate CPT code is 44950. This code covers the procedure of removing the
appendix without the presence of complications such as rupture.
2. Scenario: A patient is admitted for a laparoscopic cholecystectomy with cholangiography due
to cholelithiasis. The operative report details the removal of the gallbladder and the
performance of an intraoperative cholangiogram. What CPT codes would you use?
o Answer: For this procedure, I would use CPT code 47563 for the laparoscopic
cholecystectomy with cholangiography. This code includes both the removal of the
gallbladder and the intraoperative cholangiogram.
3. Scenario: A patient requires an emergency laparotomy for the repair of a perforated gastric
ulcer. The operative report describes the exploration of the abdominal cavity and the suturing
of the perforation. Which CPT code is appropriate?
o Answer: The appropriate CPT code for the repair of a perforated gastric ulcer via
laparotomy is 43840. This code describes the surgical repair of a gastric perforation,
including the necessary exploration of the abdominal cavity.
4. Scenario: A patient with severe Crohn’s disease undergoes a partial colectomy with ileostomy
creation. The operative report outlines the resection of the diseased portion of the colon and
the formation of the ileostomy. What CPT code would you use?
o Answer: For a partial colectomy with ileostomy creation, the appropriate CPT code is
44143. This code covers the partial removal of the colon and the creation of an
ileostomy.
 5. Scenario: A patient is admitted for a coronary artery bypass graft (CABG) procedure using two
arterial grafts and one venous graft. The operative report specifies the use of the left internal
mammary artery (LIMA), right internal mammary artery (RIMA), and the saphenous vein.
Which CPT codes would you assign?
o Answer: For a CABG using both arterial and venous grafts, the appropriate CPT codes
are 33533 for the arterial graft using the LIMA, 33534 for the additional arterial graft
using the RIMA, and 33518 for the venous graft using the saphenous vein.
6. Scenario: A patient with a diagnosis of benign prostatic hyperplasia (BPH) undergoes a
transurethral resection of the prostate (TURP). The operative report describes the removal of
prostatic tissue to alleviate urinary obstruction. What CPT code should be used?
o Answer: The appropriate CPT code for a transurethral resection of the prostate (TURP)
is 52601. This code covers the endoscopic removal of prostatic tissue to treat urinary
obstruction caused by BPH.
7. Scenario: A patient has an inguinal hernia repair with mesh placement. The operative report
details the open repair of the hernia and the use of mesh to reinforce the abdominal wall.
Which CPT code would you assign?
o Answer: For an open inguinal hernia repair with mesh placement, the appropriate CPT
code is 49505. This code includes the hernia repair and the insertion of mesh for
reinforcement.
8. Scenario: A patient with osteoarthritis undergoes a total knee arthroplasty (TKA). The
operative report includes the removal of the damaged joint surfaces and the placement of
prosthetic components. What CPT code should be used?
o Answer: The appropriate CPT code for a total knee arthroplasty (TKA) is 27447. This
code describes the surgical replacement of the knee joint with prosthetic components.
9. Scenario: A patient with endometrial cancer has a total abdominal hysterectomy with bilateral
salpingo-oophorectomy. The operative report documents the removal of the uterus, cervix,
fallopian tubes, and ovaries. Which CPT code would you use?
o Answer: For a total abdominal hysterectomy with bilateral salpingo-oophorectomy, the
appropriate CPT code is 58150. This code includes the removal of the uterus, cervix,
fallopian tubes, and ovaries.
10. Scenario: A patient with a history of recurrent diverticulitis undergoes a sigmoidectomy. The
operative report indicates the resection of the sigmoid colon and anastomosis of the
remaining bowel. What CPT code would you assign?
o Answer: The appropriate CPT code for a sigmoidectomy with anastomosis is 44145. This
code covers the resection of the sigmoid colon and the reconnection of the remaining
bowel segments.

Scenario 1: Initial Hospital Inpatient or Observation Care

Q1: A patient is admitted to the hospital for observation due to severe abdominal pain. The admitting
physician conducts a comprehensive history, examination, and medical decision-making of moderate
complexity. Which E/M code should be used?
A1: The appropriate E/M code for this scenario is 99222. This code is used for initial hospital inpatient or
observation care that includes a comprehensive history, a comprehensive examination, and medical
decision-making of moderate complexity.

Scenario 2: Subsequent Hospital Inpatient or Observation Care

Q2: On the second day of hospitalization, the patient’s abdominal pain has lessened, but the physician
needs to follow up with a detailed examination and review of test results. Which E/M code applies here?

A2: The appropriate E/M code for this scenario is 99232. This code is for subsequent hospital inpatient
or observation care that includes an expanded problem-focused interval history, a detailed examination,
and medical decision-making of moderate complexity.

Scenario 3: Same-Day Admission and Discharge

Q3: A patient is admitted to the hospital in the morning for observation after a minor head injury and is
discharged later that evening after being monitored and showing no further symptoms. What E/M code
should be used?

A3: The appropriate E/M code for this scenario is 99234. This code is used when a patient is admitted
and discharged on the same calendar day and includes an initial and subsequent hospital care visit with
a comprehensive history, a comprehensive examination, and straightforward or low complexity medical
decision-making.

Scenario 4: Complex Initial Hospital Inpatient Care

Q4: A patient with multiple chronic conditions is admitted to the hospital with acute exacerbation of
heart failure. The admitting physician performs a comprehensive history, comprehensive examination,
and high complexity medical decision-making. Which E/M code should be used?

A4: The appropriate E/M code for this scenario is 99223. This code is used for initial hospital inpatient or
observation care with a comprehensive history, a comprehensive examination, and medical decision-
making of high complexity.

Scenario 5: Simple Subsequent Hospital Inpatient or Observation Care

Q5: On the third day of hospitalization, the patient is stable, and the physician performs a problem-
focused interval history and examination with straightforward medical decision-making. Which E/M
code applies?

A5: The appropriate E/M code for this scenario is 99231. This code is used for subsequent hospital
inpatient or observation care with a problem-focused interval history, a problem-focused examination,
and straightforward or low complexity medical decision-making.

Scenario 6: Same-Day Discharge from Observation Care

Q6: A patient is placed under observation in the morning for chest pain and is discharged in the
afternoon with a diagnosis of non-cardiac chest pain after comprehensive evaluation. Which E/M code
should be used?

A6: The appropriate E/M code for this scenario is 99217. This code is used for observation care
discharge day management, which includes the final examination and discharge process.

Scenario 7: Prolonged Initial Hospital Inpatient Care

Q7: A patient is admitted with a severe infection requiring a comprehensive history, examination, and
prolonged high complexity medical decision-making by the physician. What E/M code should be used?

A7: The appropriate E/M code for this scenario is 99223. This code applies to initial hospital inpatient or
observation care requiring a comprehensive history, a comprehensive examination, and high complexity
medical decision-making.

Scenario 8: Coordination of Care in Subsequent Hospital Inpatient Care

Q8: A physician spends significant time on the third day of hospitalization coordinating with multiple
specialists and revising the patient’s treatment plan. The history and examination are detailed, and the
decision-making is of high complexity. Which E/M code is appropriate?

A8: The appropriate E/M code for this scenario is 99233. This code is used for subsequent hospital
inpatient or observation care with an interval history, a detailed examination, and high complexity
medical decision-making.

Types of Visits and Services

1. Initial Hospital Inpatient or Observation Care

o Definition: This type of visit occurs when a patient is formally admitted to the hospital
or placed under observation for the first time during their current episode of care.
o Services Included:
 Comprehensive history: A detailed account of the patient's medical history,
including past illnesses, treatments, family history, and social history.
 Comprehensive examination: A thorough physical examination of the patient.
 Medical decision-making: Assessment and plan that may range from
straightforward to high complexity, depending on the patient's condition.
o Codes:
 99221: Detailed or comprehensive history and examination with straightforward
or low complexity medical decision-making.
 99222: Comprehensive history and examination with moderate complexity
medical decision-making.
 99223: Comprehensive history and examination with high complexity medical
decision-making.
2. Subsequent Hospital Inpatient or Observation Care
 oDefinition: This type of visit is for follow-up care after the initial admission or placement
under observation, typically on subsequent days.
o Services Included:
 Interval history: A focused update on the patient’s condition since the last visit.
 Examination: A targeted physical exam relevant to the patient’s current
condition.
 Medical decision-making: Ongoing assessment and management of the patient's
condition, which may involve changes to the treatment plan based on the
patient's progress.
o Codes:
 99231: Problem-focused interval history and examination with straightforward
or low complexity medical decision-making.
 99232: Expanded problem-focused interval history and detailed examination
with moderate complexity medical decision-making.
 99233: Interval history and detailed examination with high complexity medical
decision-making.
3. Same-Day Admission and Discharge
o Definition: This type of visit occurs when a patient is admitted to the hospital or
observation status and then discharged on the same calendar day.
o Services Included:
 Comprehensive history and examination: Initial assessment and examination.
 Medical decision-making: Evaluation and management from admission through
discharge.
 Discharge services: Instructions and planning for the patient’s care after leaving
the hospital.
o Codes:
 99234: Admission and discharge on the same day with a comprehensive history,
examination, and straightforward or low complexity medical decision-making.
 99235: Admission and discharge on the same day with a comprehensive history,
examination, and moderate complexity medical decision-making.
 99236: Admission and discharge on the same day with a comprehensive history,
examination, and high complexity medical decision-making.
4. Same-Day Discharge from Observation Care
o Definition: This type of visit occurs when a patient is placed under observation and then
discharged on the same day.
o Services Included:
 Final examination: A comprehensive review of the patient’s condition.
 Discharge management: Instructions and planning for the patient’s care after
discharge, including medications, follow-up appointments, and any other
necessary care instructions.
o Code:
 99217: Observation care discharge day management, which includes the final
assessment and preparation of discharge instructions.

Summary of Codes and Services

  Initial Care (99221, 99222, 99223): Involves initial admission with a comprehensive assessment
and varying complexity of medical decision-making.
 Subsequent Care (99231, 99232, 99233): Involves follow-up visits with interval history,
examination, and ongoing medical decision-making.
 Same-Day Admission and Discharge (99234, 99235, 99236): Covers admission and discharge on
the same day with comprehensive assessment and medical decision-making.
 Same-Day Discharge from Observation (99217): Involves final assessment and discharge
planning from observation care on the same day.

Interview Questions:

1) What is principle diagnosis?

a. The condition established after study to be chiefly responsible for occasioning the admission of the
patient to the hospital for care.

2) What is Modifier?

a. To indicate that service or procedure that has been performed and has been altered by some specific
circumstance but not changed in its definition or code.

3) What is the common Modifier used in emergency?

a. 25 (Hospital and Physician Coding) and 27 (Hospital Coding)

4) What is 62 Modifier?

a. When two surgeons work together as primary surgeons performing distinct part of a procedure, each
surgeon should report his distinct operative work by adding 62 modifier.

5) Cerumen impaction?

a. Cerumen impaction is a condition in which earwax has become tightly packed in the external ear canal
to the point that the canal is blocked.

6) What are the basic guidelines of consultation?

a. 3 R’S are Request(By appropriate source like Physician or third party but not by patient’s request),
Render(Providing service by consultant) and Report(The results of consultation has to be given) .

7) What is DRG (Diagnosis Related Group) coding?

a. DRG is a system to classify hospital cases into one of the originally 747 groups. These are based on ICD
diagnoses, procedures, age, sex, discharge status, and the presence of CC-complications or
comorbidities

&MCC-Major complication and comorbidity.

8) What are the types of repairs?

a. Simple Repair: Involving primarily epidermis or dermis, or subcutaneous tissue without significant
involvement of deeper structures and requires one layer closure.

b. Intermediate Repair: Require one or more of the deeper layers of the subcutaneous tissue and
superficial fascia and heavily contaminated forthis requiring extensive cleaning.

c. Complex Repair: For this require more than layered closure Ex: scar revision, debridement.

9) How many types of closures are there?

a. One layer closure is simple repair. Two layers of more is intermediate repair. Up to muscle closure
complex repair exam

10)Lesion Excision

a. Surgical removal of lesion means any abnormal skin condition.

11)What is close reduction and open reduction?

a. Fracture reduced without incision is Closed Reduction and the one that is reduced with an incision is
Open Reduction

12)Closed facture is treated with open reduction? (Is this True)

a. Yes- It is treated with open reduction with internal fixation(ORIF)

13)Basic Surgical coding guidelines in surgery section?

a. Differs body system to system and main guidelines are anesthesia and fluoroscopic guidance observed
or done

14)Radiology coding?

a. 70000 series mainly having two components like professional and Technical component. Any
procedure which involves images called as radiology coding. Modifiers are 26, TC, 50, RT, LT, 59.

15)What are basic key components in evaluation and management?

a. 7 Components are History, Examination, MDM-Medical Decision Making , Counseling, Coordination of

care, Nature of presenting problem and Time
b. The 3 basic key components are HX, Exam and MDM.

What is the basic difference between 95 and 97 guidelines?

a. 95 guidelines are based on body systems 97 systems based on bullet points.

2) What is the basic difference between emergency and outpatient department?

a. The basic difference between ED outpatient departments is that in Emergency there is no

differentiation between new or established, but in outpatient there is new or established.

3) Abbreviation of HCPCS? Mention about level 1,level 2,level 3?

a. HCPCS: Health Care Common Procedure Coding System.

b. Level 1: Outpatient Setup Modifiers

c. Level 2: HCPCS National Modifiers Alphanumerical.

d. Level 3: Local Modifiers.

4) Difference between inpatient and outpatient?

a. Outpatient is the patient comes gets treated and leaves the same day.

b. Inpatient is the patient gets admitted with a overnight stay, gets treated and gets discharged.

5) What is MDM?

a. MDM refers to the complexity of establishing a diagnosis or selecting a management option from the
History and Examination part.

6) What is UHDDS?

a. Uniform Hospital Discharge Data Set(UHDDS) is defined as “all conditions that coexist at the time of
admission, that develop subsequently, or that affect the treatment received or the length of stay”.
Diagnoses that relate to an earlier episode which have no bearing on the current hospital stay are to be
excluded.

7) What is 24, 57,62 and 73 modifier?

a. 24 – Unrelated Evaluation and Management Service by the Same Physician during a Postoperative
Period

57 – Decision for Surgery

62 - Two Surgeons
73 - Discontinued Outpatient Hospital/Ambulatory Surgery Center (ASC) Procedure prior to the
Administration of Anesthesia

8) Doctor diagnosis foreign body in eye, he prescribed eye drops? What is MDM level?

a. MDM level is Low or Straight forward(Level 2)

9) Basic coding guidelines between inpatient and outpatient coding?

a. Uncertain conditions can be coded such a possible, probable, suggestive when it is documented on
discharge day but uncertain conditions should not be coded in Outpatient coding

10)What is abbreviation of NCC coding and use?

a. NCC-National Correct Coding Initiative.

Used for identifying bundling and unbundling of services.

11)Lesion is 2X3 cm and the margin is 0.5 mm calculate the lesion size?

a. Add lesion size and margins size . Here it is 2 cms.+0.5mm+0.5mm=2.1 cms.

12)Abbreviation of POA?

a. Present On Admission-POA

13)Brief about E and M?

a. E/M service Medical practice Any diagnostic and therapeutic procedure that may be performed by a
health care provider at a specific location. See History of present illness, General multi-system
examination, Past, family and/or social history, Review of Systems, Single organ system examination. Cf
Physican test, Procedure.

14)How to define new and established patient?

a. A new patient is one who has not received any professional service from the physician or another
physician of the same specialty who belongs to the same group practice, within the past 3 years

b. An established patient is one who has received professional services from the physician or another
physician of the same specialty who belongs to the same group practice, within the last 3 years.

15)Define consultation?

a. A Consultation is a type of E/M Service provided by a physician at the request of another physician or
appropriate source to either recommended care for a specific condition or problem or to determine
whether to accept responsibility for ongoing management of the patient’s entire care or for the care of a
specific condition or problem.
16)What is critical care?

a. Critical care is the direct delivery of service by physician of medical care for a critically ill or critically
injured patient.

b. A Critical illness or injury is one which accurately impairs one or more vital organ systems such that
there is a life threatening event in the patient’s condition.

17)What is Closed fracture and open fracture?

a. Closed fracture is one in which the fractured site is not exposed to outside environment.

b. Open fracture is one in which the fracture site is exposed to outside environment(air)

18)Abbreviation of CCI and CPT?

a. CCI- Correct Coding Initiative and CPT- Current Procedural Terminology.

19)Difference between principal diagnosis and primary diagnosis?

a.ThePrimary Diagnosis is an outdated term in outpatient settings. The term was changed to First-listed
Diagnosis some years ago, and it is the main condition treated or investigated during the relevant
episode of outpatient (ambulatory)healthcare.

In an inpatient setting, the term "Primary Diagnosis" is still used to reference the condition that was the
most serious and/or resource intensive during that hospitalization.

20)What is Surgical pathology?

a. Surgical pathology involves the gross and microscopic examination of surgical specimens, as well as
biopsies submitted by surgeons and non-surgeons such as general internists, medical subspecialists,
dermatologists, and interventional radiologists.

21)Abbreviation of BCC?

a. Basal Cell Carcinoma

22)Common modifiers used in radiology?

a. 26, TC, 50, LT and RT

23)Difference between critical care and emergency care?

a. Emergency Care:

· Emergency department
· Emergency Physicians (trained and qualified in the specialty of emergency medicine after mbbs
graduation) Emergency department

· Diagnosis is not required for initiation of treatment

Critical Care:

· Intensive care units

· Intensivists (qualified in critical care medicine after completion of postgraduation in medicine, surgery
or anesthesia)

· Diagnosis necessary and required for continuation of treatment

24)what is inpatient and emergency room coding?

a. Emergency Coding is 24-hours without appointment can walk in, get treatment and discharged.

b. Inpatient Coding is getting admitted with an overnight stay.

Question: Who is a qualified health care professional (QHP)?

Academy answer: Nurse practitioners and physician assistants. Physician extenders who are licensed to
practice medicine.

Question: Does staff time count?

Academy answer: Only staff that is licensed to practice medicine counts when coding is based solely on
time.

Question: Has the implementation of add-on HCPCS code G2211 been delayed?

Academy answer: Yes. HCPCS code G2211 Visit complexity inherent to evaluation and management
associated with medical care services that serve as the continuing focal point for all needed health care
services and/or with medical care services that are part of ongoing care related to a patient’s single,
serious condition or a complex condition. (Add-on code, list separately in addition to office/outpatient
evaluation and management visit, new or established) has been deleted for the years according to CMS
publication Dec 21.

Q&As About Component 1: Number and Complexity of Problems Addressed at the Encounter

Question: How is "a self-limited or minor problem" defined?

AMA answer: A problem that runs a definite and prescribed course, is transient in nature, and is not
likely to permanently alter health status.
Question: How is "a stable, chronic illness" defined?

AMA answer: A problem with an expected duration of at least a year or until the death of the patient.
For the purpose of defining chronicity, conditions are treated as chronic whether or not stage or severity
changes (eg, uncontrolled diabetes and controlled diabetes are a single chronic condition). “Stable” for
the purposes of categorizing medical decision making is defined by the specific treatment goals for an
individual patient. A patient who is not at their treatment goal is not stable, even if the condition has not
changed and there is no short-term threat to life or function. For example, a patient with persistently,
poorly controlled blood pressure for whom better control is a goal is not stable, even if the pressures are
not changing and the patient is asymptomatic. The risk of morbidity without treatment is significant.

Question: How is "an acute, uncomplicated illness or injury" defined?

AMA answer: A recent or new short-term problem with low risk of morbidity for which treatment is
considered. There is little to no risk of mortality with treatment, and full recovery without functional
impairment is expected.

A problem that is normally self limited or minor, but is not resolving consistent with a definite and
prescribed course is an acute uncomplicated illness.

Question: How is "chronic illness with exacerbation, progression, or side effects of treatment"
defined?

AMA answer: A chronic illness that is acutely worsening, poorly controlled or progressing with an intent
to control progression and requiring additional supportive care or requiring attention to treatment for
side effects, but that does not require consideration of hospital level of care.

What are clinical examples of an undiagnosed new problem with uncertain prognosis?

AMA answer: A problem in the differential diagnosis that represents a condition likely to result in high
risk of morbidity without treatment.

Q&As About Component 2: Amount and/or Complexity of Data to be Reviewed and Analyzed

Question: How is "each unique source" defined?

AMA answer: An external physician or other QHP who is not in the same group practice or is of a
different specialty or subspecialty.

This includes licensed professionals who are practicing independently.

The individual may also be a facility or organizational provider such as from a hospital, nursing facility, or
home health care agency.

Question: Do we receive credit for each unique test we either order or provide the
interpretation/report, past or present?
AMA answer: Any test with a CPT code current or past for which you receive/received separate payment
does not count in this category.

Question: Who qualifies as an independent historian?

AMA answer: An individual (e.g., parent, guardian, surrogate, spouse, witness) who provides a history in
addition to a history provided by the patient who is unable to provide a complete or reliable history
(e.g., due to developmental stage, dementia, or psychosis) or because a confirmatory history is judged
to be necessary.

In the case where there may be conflict or poor communication between multiple historians and more
than one historian is needed, the independent historian requirement is met.

Question: What constitutes "moderate" in Category I? Is it three out of the four possible bullets or
three from any combination in this category?

AMA answer: The requirements in the category can be met any way (as long as there are 3).

All 3 can be ordering tests or there can be 2 ordered tests and 1 review of a test result.

There is a lot of flexibility to meet the requirements in this category. As long as there are at least three
elements (i.e., bullet points) performed, regardless of which specific ones are performed, the
requirements are met.

Question: Does a letter to the referring source count for discussion of management or test
interpretation with external physician/QHP or appropriate source?

AMA answer: No. To qualify, discussion requires two-way communication.

Question: How is "appropriate source for the purpose of the discussion of management" defined?

AMA answer: An appropriate source includes professionals who are not health care professionals, but
may be involved in the management of the patient (e.g., lawyer, parole officer, case manager, teacher).
It does not include discussion with family or informal caregivers.

Q&As About Component 3: Risk of Complications and/or Morbidity of Mortality of Patient

Management

Question: Is minor or major surgery defined by global periods as it is for coding?

AMA answer: No. The physician’s expertise defines minor surgery with identified patient or procedure
risk factors, or elective major surgery with or without risk factors.

Question: What are "social determinants of health?"

AMA answer: Economic and social conditions that influence the health of people and communities.
Examples may include food or housing insecurity.