Coding Corner Question: March

Evaluation and Management Components

Medicare carriers are using recovery auditor contractors and actively auditing codes 99204 and 99205, so make sure your knowledge on evaluation and management (E/M) components is complete. Here are some questions to test your coding skills.

1. If a patient returns to the office with two established problems that are worsening, what is the level for the number of diagnoses or treatment options?
   1. Minimal
   2. Limited
   3. Multiple
   4. Extensive
   5. None of the above
2. A chief complaint must be listed in the patient’s medical record for each visit.
   1. True
   2. False
3. How many elements are needed for an extended history of present illness (HPI)?
   1. One
   2. Two
   3. Three, or the status of at least three chronic or inactive conditions
   4. Four
   5. Four, or the status of at least four chronic or inactive conditions
4. What elements are needed to achieve a comprehensive history level for a new patient?
   1. Chief complaint; extended HPI; extended review of systems; no past, family, and social history
   2. Chief complaint; brief HPI; extended review of systems; no past, family, and social history
   3. Chief complaint; extended HPI; complete review of history; two of the past, family, and social history
   4. Chief complaint; extended HPI; complete review of history; three of the past, family, and social history
   5. None of the above
5. What level of risk is documented if a patient is diagnosed with an acute or chronic illness that may pose a threat to life or bodily function, such as severe rheumatoid arthritis?
   1. Minimal risk
   2. Low risk
   3. Moderate risk
   4. High risk
   5. None of the above

click here for the answers.