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Basic Procedural Coding Test Chapters 7 & 8
April 23, 2014
Code the following:
1. A 35 year old patient receives an IM (intramuscular} injection of the Lyme disease vaccine.
2.
A physician documents that critical care services were provided to a 12-year-old patient for 90 minutes. What is
the correct E/M code(s} assignment for this service?
3.
A 20 year old patient is seen for an intravenous hydration that was infused over 45 minutes.
4.
Electrocardiogram, routine ECG with at least 12 leads; tracing only without interpretation and reporting.
5.
A 60 year old patient who has never been seen by this physician has an office visit for abdominal pain with a
detailed history, a detailed examination, and medical decision making of low complexity.
6. The physician sees a patient in Sunny Acres Nursing Facility as a follow-up visit. The patient has a urinary tract
infection that is not responding to medication . The physician documents a problem-focused interval history,
expanded problem-focused exam, and the medical decision making was of moderate complexity. Whatis the
correct CPT code assignment for this service?
7. A patient is seen in the emergency room for severe low back pain. The ED physician performs an expanded
problem -focused history, problem focused examination, and the medical decision-making was of moderate
complexity. What is the correct E/M code assignment for this service?
8. Patient was diagnosed with actinic keratosis with lesions on several locations of the face . The patient receives
irradiation of the areas with photodynamic therapy illuminator for 15 minutes.
9. A 67-year-old patient with multiple medical problems is currently taking six prescriptions and several over-thecounter agents. The primary care physician has a concern about side effects; therefore, the patient is referred
to a pharmacist for assessment and management of medications. The pharmacist assesses the treatment and
makes recommendations during the 10 minute face-to-face visit.
Answer the following:
10. Give the definition of "chief complaint".
11. How many key components are required when coding emergency room evaluation and management?
12. List three services that are included in and not reported separately if performed to facilitate the infusion or
Injection of drugs or hydration.
13. True or false, acupuncture services CPT codes can be found in the Medicine section.
14. True or false, consultations are provided only for inpatient hospital services.
15. The patient was seen in the physician's office after falling and injuring her ankle. The physician performed a
brief HPI, a problem focused exam, and the decision making was straight-forward. What component{s) of the
history is missing from this scenario?
16. A patient is seen on January 23, 2008 by a primary care physician who is a member of University Associates. A
cardiologist (also a member of University Associates) sees the patient on November 24, 2009. Would the visit
on November 241h be classified as a new or an established patient?
17. An established patient is seen in the physician's office for counseling after having an extremely high cholesterol
reading and hypertension. Which range of codes would be used to select the appropriate CPT code for these
services?
18. Which range of codes would be used to select the appropriate CPT code for immunization
Administration for Vaccines/Toxoids?
19. List the description of two Other Services and Procedures that can be found in the Medicine Section
of CPT.
20. List the description and CPT code of two services that are "new" codes in the Evaluation and
Management
Section of CPT for 2014.
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