CCEP Lesson 9 Module 1.b Homework – Office Visit Services

Select the E/M code for a new patient office encounter involving evaluation and management of two stable chronic illnesses. Two lab tests are ordered that will be processed and billed by the clinic. Prescription medications were refilled with no adjustments.

Column 1:        Moderate (2 stable chronic illnesses)

Column 2:        N/A

Column 3:        Moderate (RX management)

Select the E/M code for a new patient encounter involving an acute, uncomplicated illness. The clinician requires no data and recommends OTC meds of low risk to the patient.

Column 1:        Low (acute uncomplicated illness)

Column 2:        N/A

Column 3:        Low

Select the E/M code for an established patient office encounter involving a mild asthma exacerbation. A nebulizer treatment is administered in the office with good results. Prescriptions for home medications are refilled.

Column 1:        Moderate (1 chronic illness with exacerbation)

Column 2:        N/A

Column 3:        Moderate (RX management)

True or False? When an office or other outpatient services E/M is selected based on time, count both face-to-face time and non-face-to-face time on the date of the encounter. Only clinician time is counted (not ancillary staff). Therefore, a coder may count the time spent on the patient’s behalf before, during and after the encounter, as long as it is on the date of service.

A 64 yof established patient with hypertension complains of lightheadedness and palpitations. Taking medication as instructed. BP is elevated in clinic today. Relevant history review and exam performed reveal she has had a recent death of her husband of 37 years. Physician has an extensive conversation with the patient about the possible impact this event may have on her current symptoms. Additional studies are ordered. Results will be reviewed for necessary revisions in current treatment plan. Total encounter time of 41 minutes is documented. Select the appropriate E/M code for this encounter: