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Quizzes > Quizzes for Business > Healthcare

E/M Coding Basics Quiz Challenge

Sharpen Your Evaluation and Management Coding Skills

Difficulty: Moderate
Questions: 20
Learning OutcomesStudy Material
Colorful paper art promoting an EM Coding Basics Quiz.

This E/M coding quiz helps you practice choosing accurate evaluation and management codes using brief notes and billing cues. Work through 15 multiple-choice questions to check gaps before an exam and build speed, then keep practicing with the medical billing and coding quiz or the anesthesia coding skills check .

What does "E/M" stand for in medical coding?
Evaluation and Management
Examination and Monitoring
Examination and Management
Evaluation and Methodology
E/M is the standard abbreviation for Evaluation and Management in coding guidelines. It refers to the process of assessing and managing a patient's healthcare needs.
Which element is NOT one of the three key components used to select an outpatient E/M service level?
History
Physical Examination
Payment Method
Medical Decision Making
The three key components for outpatient E/M coding are history, physical examination, and medical decision making. Payment method is not a component used to determine the code level.
Which CPT code range covers office or other outpatient E/M services?
99441 - 99443
99202 - 99215
99381 - 99397
99221 - 99223
Codes 99202 - 99215 are used for office or other outpatient evaluation and management services. The other ranges apply to inpatient care, preventive services, and telephone services respectively.
Which factor is a key element in determining Medical Decision Making (MDM) complexity?
Physician's license
Complexity of diagnoses
Patient's age
Room charge
Medical Decision Making complexity is determined by factors such as the number and complexity of diagnoses or management options. Patient age, room charges, and physician license status do not factor into MDM complexity.
Which documentation format organizes notes into Subjective, Objective, Assessment, and Plan?
Diagnosis Related Group (DRG)
LOINC coding
ICD framework
SOAP note
The SOAP note format stands for Subjective, Objective, Assessment, and Plan. It is a widely used structure to document patient encounters and progress.
Which Medical Decision Making level includes multiple diagnoses, moderate data complexity, and moderate risk?
Straightforward
High
Low
Moderate
Moderate MDM involves multiple diagnoses or management options, moderate data complexity, and moderate risk of complications. It is one step above low complexity and below high complexity.
When using time-based billing for an outpatient E/M visit, what does total time include?
Face-to-face time only
Both face-to-face and non - face-to-face time
Non - face-to-face time only
Documentation time only
Time-based billing includes both face-to-face and non - face-to-face activities such as reviewing records and coordinating care. Documentation time alone is not separated out.
A provider documents 3 HPI elements, 2 ROS systems, 1 PMH item, and exam of 2 organ systems. What history level is supported?
Expanded problem-focused
Problem-focused
Comprehensive
Detailed
With a brief HPI (1 - 3 elements) and an extended ROS (2 - 9 systems), the history is expanded problem-focused. Detailed and comprehensive require more extensive HPI, ROS, and PMH documentation.
Which of the following best describes data complexity in MDM?
Length of stay in hospital
Patient's height and weight
Number of follow-up visits
Number of diagnoses and amount of data reviewed
Data complexity is determined by the number of data points reviewed (labs, tests, documents) and the complexity of those data reviews. Visit frequency or anthropometrics are not part of data complexity.
Which of the following is a common E/M coding error?
Upcoding to a higher level without support
Documenting vitals
Underbilling only
Using ICD codes instead of CPT
Upcoding without proper documentation is a frequent error that can lead to audits and penalties. Using ICD codes instead of CPT and documenting vitals are not typical coding errors.
Which CPT code is used for prolonged office or other outpatient evaluation and management services as an add-on?
99357
99354
99215
99417
CPT code 99417 is the add-on code for prolonged outpatient E/M services beyond the highest level. Codes 99354 and 99357 are for inpatient prolonged services.
A physician spends 30 minutes counseling a patient with minimal exam documented. Which outpatient code applies by time?
99202
99203
99212
99204
Under the 2021 guidelines, 30 - 44 minutes of total time qualifies for code 99203. The minimal exam does not prevent time-based code selection when counseling predominates.
Which two components can be used to select an outpatient E/M code level under the 2021 guidelines?
Medical Decision Making or total time
Physical exam and risk
History and exam
Location of visit and patient age
The 2021 outpatient E/M guidelines allow level selection based on either Medical Decision Making or total time. History and exam are no longer used for code selection in most scenarios.
A well-controlled diabetic patient presents for routine follow-up. How is the risk category classified under MDM?
Minimal risk
Low risk
Moderate risk
High risk
A stable, well-controlled chronic illness is considered minimal risk in the MDM table. Low and moderate risks apply to more complex or unstable conditions.
Which element is NOT required to be documented to support Medical Decision Making?
Patient's employment details
Level of risk
Number of diagnoses
Amount and complexity of data reviewed
MDM documentation requires diagnoses or options, risk, and data complexity. A patient's employment details are not part of the MDM criteria.
Under the 2021 outpatient E/M guidelines, which components no longer determine the code level?
Total time
Medical Decision Making
History and examination
Patient complexity
The 2021 outpatient E/M guidelines removed history and examination as factors for code level determination. Only MDM or total time are used to select the appropriate code.
A provider documents 20 minutes of face-to-face care and 30 minutes of preparation and follow-up. Which code applies by time?
99417
99204
99205
99203
Total time of 50 minutes falls into the 45 - 59 minute range, which is code 99204 under the time-based outpatient E/M guidelines. Prolonged add-on code 99417 only applies beyond 75 minutes.
Reviewing six laboratory panels, three imaging studies, and consulting an external report contributes to what level of data complexity in MDM?
Minimal
Moderate
Limited
High
High data complexity involves reviewing multiple independent data sources such as labs, imaging, and external reports. This level exceeds the thresholds for moderate complexity.
Which documentation element is critical to support a high-risk MDM for level 5 outpatient visits?
Total word count of the note
Patient satisfaction score
Number of pages in the medical record
Evidence of a high probability of severe complications
To support high-risk MDM, documentation must show a high probability of severe complications, morbidity, or mortality. Note length or satisfaction scores are not criteria.
Under the MDM risk table, initiating an IV infusion for antibiotic therapy is classified as which risk category?
Low risk
High risk
Minimal risk
Moderate risk
The initiation of IV drug therapy carries moderate risk of complications and is classified accordingly in the MDM risk table. Low risk is reserved for minor procedures and prescription drugs.
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Learning Outcomes

  1. Analyse E/M coding guidelines to select correct codes.
  2. Identify service levels based on documentation criteria.
  3. Apply documentation standards for accurate billing submissions.
  4. Evaluate common E/M coding errors to optimize claims.
  5. Demonstrate proficiency in code selection for patient visits.
  6. Master compliance with evaluation and management regulations.

Cheat Sheet

  1. Master the 3 Pillars of E/M Coding - Grab your detective hat and dive into the three key components of E/M coding: history, examination, and medical decision making (MDM). Understanding these pillars is like finding the treasure map to the perfect code level every time!
  2. Get Up to Speed on 2021 Updates - The 2021 changes let you pick codes based on either MDM or total time, making your documentation lighter and smarter. Embrace this flexibility to streamline your workflows and boost your coding confidence!
  3. Decode the Four MDM Levels - From straightforward to high complexity, each MDM level hinges on problem complexity, data review, and risk of complications. Learning these tiers is like leveling up in a game - each stage tests your skills and rewards precision!
  4. Focus on What Matters in Outpatient Visits - In office/outpatient E/M encounters, document history and exam only as medically appropriate, then zero in on MDM or total time. This targeted approach keeps your notes concise and audit-ready!
  5. Time-Based Coding Demystified - Total time on the encounter date now includes everything from test reviews to patient counseling and charting. Track every minute - your documented effort translates directly into the appropriate code level!
  6. Spot Common E/M Coding Pitfalls - Undercoding? Overcoding? Both can cost you - either in revenue or audit headaches. Learn the red flags and ensure your documentation fully supports the service level billed!
  7. Use the Table of Risk Like a Pro - The Table of Risk is your compass for gauging patient management risk and dialing in the right MDM level. Master this tool to confidently navigate complex cases!
  8. Practice with Real-World Case Studies - Hands-on practice is your secret weapon. Work through case scenarios, apply the guidelines, and watch your coding accuracy soar!
  9. Stay Audit-Ready with Compliance Tips - Keep one eye on evolving E/M regulations to ensure accurate billing and dodge audit penalties. Staying current today saves big headaches tomorrow!
  10. Leverage Handy Reference Tools - Coding cards, checklists, and cheat sheets are your best buddies when you need a quick reminder. Keep these resources at your fingertips to reinforce learning and speed up your coding process!
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