Deck 6: Introduction to CPT and Place of Coding Services

Question 1

Evaluation and management (E/M) services can be performed in which of the following locations?

A) physician offices only
B) physician offices and hospitals only
C) physician offices, hospitals, and nursing homes
D) physician offices, inpatient and outpatient facilities, and patients' homes

Answer 1

physician offices, inpatient and outpatient facilities, and patients' homes

Question 2

The modifier -25 is used to indicate:

A) prolonged evaluation and management (E/M) service.
B) unrelated E/M service by the same physician during a postoperative period.
C) significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service.
D) reduced services.

Answer 2

significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service.

Question 3

The first section of the CPT code book is:

A) Anesthesia.
B) Surgery.
C) Medicine.
D) Evaluation and Management .

Answer 3

Evaluation and Management .

Question 4

The Health Insurance Portability and Accountability Act (HIPAA) supports the:

A) use of local codes.
B) increased use of temporary codes for emerging technology.
C) elimination of local, temporary codes.
D) increased use of nonstandard CPT codes.

Question 5

The symbol • used with a CPT code indicates:

A) revised code.
B) new code.
C) new or revised text.
D) add-on code.

Question 6

The modifier -57 is used to indicate:

A) repeat procedure by the same physician.
B) unrelated evaluation and management (E/M) service by the same physician during a postoperative period.
C) significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service.
D) a decision for surgery.

Question 7

The modifier -52 is used to indicate:

A) prolonged evaluation and management (E/M) service.
B) unrelated E/M service by the same physician during a postoperative period.
C) significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service.
D) reduced services.

Question 8

All of the following are sections of Category I CPT codes EXCEPT:

A) Evaluation and Management.
B) Surgery.
C) Medicine.
D) Emergency Room Services.

Question 9

The type of procedure codes that use a five-digit numeric code and descriptor are:

A) ICD-9-CM codes.
B) Category I CPT codes.
C) Category II CPT codes.
D) Category III CPT codes.

Question 10

The current CPT system uses codes with:

A) 3 digits.
B) 4 digits.
C) 5 digits.
D) 6 digits.

Question 11

The ▲ symbol used with a CPT code indicates:

A) revised code.
B) new code.
C) new or revised text.
D) add-on code.

Question 12

In what year did CMS require state Medicaid agencies to use CPT codes for reporting outpatient hospital procedures as part of the Omnibus Budget Reconciliation Act?

A) 1977.
B) 1986.
C) 1992.
D) 2006.

Question 13

The modifier -32 is used to indicate:

A) mandated services (used when requested by the payer).
B) unrelated E/M service by the same physician during a postoperative period.
C) significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service.
D) reduced services.

Question 14

If a physician began an initial gynecological exam on a patient but discontinued it due to the patient's extreme discomfort, the modifier would be:

A) -25.
B) -32.
C) -52.
D) -57.

Question 15

What letter appears in the last field of CPT Category II codes to distinguish them from Category I codes?

A) F
B) P
C) T
D) V

Question 16

The symbol + used with a CPT code indicates:

A) revised code.
B) new code.
C) new or revised text.
D) add-on code.

Question 17

To report that the description of a service or procedure has been altered in some way, the coder should use a:

A) Category II CPT code.
B) Category III CPT code.
C) modifier.
D) written explanation.

Question 18

CPT Category II codes are used principally:

A) for providing more information about the diagnosis.
B) as temporary codes for emerging technology.
C) for performance measurement.
D) to describe the procedure performed by the physician.

Question 19

The temporary codes used for emerging technology, services, or procedures are:

A) Category I CPT codes.
B) Category II CPT codes.
C) Category III CPT codes.
D) ICD-10-CM codes.

Question 20

The Current Procedural Terminology (CPT) is published by the:

A) World Health Organization (WHO).
B) Centers for Medicare and Medicaid Services (CMS).
C) American Medical Association (AMA).
D) National Center for Health Statistics.

Question 21

When a second physician examines a patient and renders an opinion, the service is referred to as a:

A) consultation.
B) referral.
C) specialist visit.
D) wellness examination.

Question 22

Dimensions of a history of present illness (HPI) include all of the following EXCEPT:

A) location in the body where the chief complaint is occurring.
B) age-appropriate dietary status.
C) the situation that is associated with the pain or symptom.
D) how long the symptom or pain has been present and/or how long it lasts.

Question 23

In a coding a physical examination, all of the following organ systems are recognized EXCEPT:

A) head, including the face.
B) eyes.
C) respiratory.
D) skin.

Question 24

Details about the health status or cause of death of parents, siblings, and children would be part of a:

A) history of present illness.
B) past history.
C) family history.
D) social history.

Question 25

The transfer of total care or a specific portion of care of a patient from one physician to another is called a(n):

A) authorization.
B) consultation.
C) office visit.
D) referral.

Question 26

Details about a patient's current employment or school history would be part of a:

A) history of present illness.
B) past history.
C) family history.
D) social history.

Question 27

Components that define the level of evaluation and management (E/M) services include all of the following EXCEPT:

A) the extent of the history documented.
B) the location of the procedure or service.
C) the complexity of the medical decision making documented.
D) time.

Question 28

The three key components used to select the appropriate evaluation and management (E/M) code include:

A) history, patient age, and time.
B) medical decision making, presenting problem, and counseling.
C) examination, chief complaint, and place of service.
D) history, examination, and medical decision making.

Question 29

If an examination includes an extended exam of the affected body area(s) and other symptomatic or related organ systems, it is considered a(n):

A) problem-focused exam.
B) expanded problem-focused exam.
C) detailed exam.
D) comprehensive exam.

Question 30

A statement, usually in the patient's words, describing the symptom, problem, condition, or other factor that is the reason for the encounter is called the:

A) chief complaint.
B) primary diagnosis.
C) principal diagnosis.
D) reason for complaint.

Question 31

Most services for established patients and subsequent care include all the following components EXCEPT:

A) expanded problem, focused history.
B) expanded problem, focused examination.
C) medical decision making of low complexity.
D) medical decision making of high complexity.

Question 32

A chronological description of the patient's illness from the first sign or symptom to the present is the:

A) history of present illness.
B) past history.
C) family history.
D) social history.

Question 33

The four types of examinations used in determining the level of evaluation and management (E/M) services are:

A) problem focused, expanded problem focused, detailed, and comprehensive.
B) problem focused, expanded problem focused, complete, and comprehensive.
C) problem focused, detailed, comprehensive, and complete.
D) expanded problem focused, detailed, expanded detailed, and comprehensive.

Question 34

A description of how long the symptom or pain has been present is referred to as the:

A) timing.
B) duration.
C) severity.
D) quality.

Question 35

An expanded problem focused history would include all of the following EXCEPT:

A) chief complaint.
B) brief history of present illness.
C) brief family history.
D) problem-pertinent review of systems.

Question 36

Which of the following dimensions of a history of present illness (HPI) refers to actions taken to make the pain or symptom change?

A) Associated signs and symptoms
B) Context
C) Modifying factors
D) Quality

Question 37

A social history would include which of the following?

A) prior major illnesses and injuries
B) current medications
C) the situation that is associated with the pain or symptom
D) marital status and/or living arrangements

Question 38

If a history includes a review of the chief complaint (CC) and a brief history of present illness (HPI) only, it is considered a(n):

A) problem-focused history.
B) expanded problem-focused history.
C) detailed history.
D) comprehensive history.

Question 39

A new patient is considered one who has NOT received professional services from the physician or another physician of the same specialty in the same group within the past:

A) 1 year.
B) 2 years.
C) 3 years.
D) 5 years.

Question 40

The most-often reported evaluation and management (E/M) services are:

A) office and other outpatient services.
B) hospital (inpatient) services.
C) emergency room services.
D) consultations.

Question 41

Category I CPT codes are used to describe a procedure or service.

Question 42

Medical decision making (MDM) is measured by all of the following components EXCEPT the:

A) cost associated with the recommended procedure.
B) risk of significant complications.
C) number of medical records or tests that must be analyzed.
D) number of possible diagnoses that must be considered.

Question 43

Counseling with a patient or family can be considered in coding an evaluation and management (E/M) service if it pertains to:

A) results of diagnostic testing.
B) prognosis.
C) risks and benefits of treatment options.
D) all of the above.

Question 44

The Current Procedural Terminology (CPT) was first published by the American Medical Association (AMA) in 1966.

Question 45

If a patient presented with a condition that resulted in minimal management options, the medical decision making (MDM) would be considered:

A) straightforward.
B) low complexity.
C) moderate complexity.
D) high complexity.

Question 46

CPT codes describe the main reason for the encounter or visit.

Question 47

CPT codes are used to determine the amount of reimbursement the provider will receive.

Question 48

The review of systems (ROS) is considered part of:

A) history of the patient.
B) examination of the patient.
C) medical decision making.
D) none of the above.

Question 49

In the case of a presenting problem that may NOT require the presence of a physician, if service is provided under the physician's supervision, it is considered:

A) minimal in nature.
B) self-limited in nature.
C) low severity in nature.
D) moderate severity in nature.

Question 50

Category III CPT codes are intended to facilitate data collection by coding certain services that contribute to positive health outcomes.

Question 51

An inpatient is defined as a patient who has been admitted to the hospital and is expected to stay 48 hours or more.

Question 52

For evaluation and management (E/M) services, the place of service is important in determining the correct code.

Question 53

In 1983, CPT nomenclature was adopted which mandate that The Centers for Medicare and Medicaid Services (CMS) use CPT codes to report services for Medicare Part B.

Question 54

In order to consider time as a factor in evaluation and management (E/M) coding, counseling must constitute more than:

A) 25% of the visit.
B) 30% of the visit.
C) 50% of the visit.
D) 75% of the visit.

Question 55

Services that include a physical examination according to age, and appropriate immunizations and laboratory procedures, are called critical care.

Question 56

To code an evaluation and management (E/M) service properly for a new patient, which of the following elements must be documented?

A) history and examination
B) history and medical decision making
C) examination only
D) history, examination, and medical decision making

Question 57

Types of medical decision making (MDM) include: (Select all that apply)

A) straightforward.
B) low complexity.
C) moderate complexity.
D) all of the above.

Question 58

A presenting problem for which the risk of morbidity without treatment is low and full recovery is expected would be considered:

A) minimal in nature.
B) self-limited in nature.
C) low severity in nature.
D) moderate severity in nature.

Question 59

The modifier -32 is used to identify a mandated service; it is used when the service is requested by the payer.

Question 60

When a provider has a discussion with a patient or family member regarding test results, instructions, or follow-up care, this service is documented as:

A) consultation.
B) counseling.
C) referral.
D) treatment.

Question 61

A review of the patient's prior experience with illnesses, injuries, and treatments is the ________.

Question 62

The risk of significant complications, morbidity, and/or mortality is a factor in determining the level of medical decision making (MDM).

Question 63

A physician providing a consultation must document his or her opinion in the medical record and render the opinion in writing to the requesting physician.

Question 64

E/M codes are used to report a significant portion of physician services.

Question 65

No distinction is made between new and established patients in coding for emergency room care.

Question 66

A description of the level of symptoms or pain or their ranking on a scale is the level of ________.

Question 67

A review of a patient's past experiences with illnesses, injuries, and treatments is called a social history.

Question 68

A concise statement, usually stated in the patient's words, describing the symptom, problem, or condition is called the ________.

Question 69

The two-digit code placed after the main CPT code to indicate that the description of the service or procedure has been altered is a(n) ________.

Question 70

A description of other things that happen when the symptom or pain occurs is referred to as a "modifying factor."

Question 71

An inventory of the body obtained when the physician asks the patient a series of questions to identify signs of illness and/or symptoms the patient may be experiencing is called a(n) ________.

Question 72

When time is reported using CPT codes, it documents the exact amount of time a physician spends with a patient.

Question 73

A comprehensive exam would include a general multisystem exam or a complete exam of a single organ system.

Question 74

A discussion with the patient and/or a family member to address risk-factor reduction is considered ________.

Question 75

The transfer of the total care or a portion of care of a patient from one physician to another is a(n) ________.

Question 76

A patient who has received professional services from the physician or a physician in the same group within the past 3 years is referred to as a(n) ________ patient.

Question 77

The set of temporary codes used for emerging technology, services, and procedures is known as ________ CPT.

Question 78

A history that involves the chief complaint (CC) and a brief history of present illness (HPI) is a(n) ________ history.

Question 79

An established patient is defined as one who has received professional service from the physician or another physician of the same specialty in the same group within the last 5 years.

Question 80

When an evaluation and management (E/M) code is assigned, the patient's medical record must contain the clinical data to support it.