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CPMA 2024/25 LATEST EXAM UPDATE WITH
MULTIPLE CORRECTLY ANSWERED QUESTIONS
ALREADY GRADED A+ |WITH APPROPRIATE
RATIONALES
1. "Neck: No appreciable cervical adenopathy" is used for what exam element in the 1995 Documentation Guidelines? A. Neck B. Musculoskeletal C. Skin D. Lymphatic ...ANS: D. Lymphatic Rationale: When determining the level of exam under the 1995 CMS Documentation Guidelines, make sure to read the information documented instead of relying on the headings of the documentation. What is documented for neck in the question is counted for lymphatic (organ system) rather than neck (body area). 2. 65 year-old was admitted in the hospital two days ago and is being examined today by his primary care physician, who has been seeing him since he has been admitted. Primary care physician is checking for any improvements or if the condition is worsening. CHIEF COMPLAINT: CHF INTERVAL HISTORY: CHF symptoms worsened since yesterday. Now has some resting dyspnea. HTN remains poorly controlled with systolic pressure running in the 160s. Also, I'm concerned about his CKD, which has worsened, most likely due to cardio-renal syndrome.
REVIEW OF SYSTEMS: Positive for orthopnea and one episode of PND. Negative for flank pain, obstructive symptoms or documented exposure to nephrotoxins. PHYSICAL EXAMINATION: GENERAL: Mild respiratory distress at rest VITAL SIGNS: BP 168/84, HR 58, temperature 98.1. LUNGS: Worsening bibasilar crackles CARDIOVASCULAR: RRR, no MRGs. EXTREMITIES: Show worsening lower extremity edema. LABS: BU ...ANS: Subsequent Hospital Visit (99231-99233) Rationale: This is a subsequent hospital visit which is reported with code range 99231-99233. The patient was admitted in the hospital two days ago and the primary care physician has been seeing the patient since he has been admitted to the hospital. Initial Hospital Visit (99221-99223) is when the doctor is initially admitting the patient to the hospital. Inpatient Consultation (99251-99255) is when the provider requests for another provider to see the patient to recommend care for a specific condition or to accept ongoing management for the patient's condition. Established Patient Office/Outpatient Visit (99211-99215) is when the patient is being seen in the office setting, not the hospital.
3. 72 - year-old was admitted in the hospital three days ago and is being examined today by his primary care physician, who has been seeing him since his admission. Te primary care physician is checking for any improvements or if the condition is worsening. CHIEF COMPLAINT: CHFINTERVAL HISTORY: CHF symptoms worsened since yesterday.
sugars and the ED provider is unable to get a history due to patient's altered mental status. An eight organ system exam is performed. The MDM is high complexity. The patient was stabilized and transferred to ICU. The ED provider documents total critical care time 25 minutes. What CPT® code is reported? a. 99285 b. 99223 c. 99291 d. 99236 ...ANS: a. 99285 Rationale: According to CPT® Critical Care Services guidelines: "99291 is used to report the first 30-74 minutes of critical care on a given date. Critical care of less than 30 minutes of total duration on a given date is reported with the appropriate E/M code." For this encounter the provider is short 5 minutes of 30 minutes needed to bill the critical care code. The encounter takes place in the emergency department. In the CPT® Index look for Evaluation and Management/Emergency Department. You are referred to 99281-
- For emergency room services, three out of three key components are required. In this case, the provider is unable to obtain a history due to the patient's condition. According to the CMS Documentation Guidelines, the provider must indicate the reason they could not obtain a history. The level is determined by the exam and MDM. The exam is comprehensive (eight organ systems) and MDM is hig 6. A 28 year-old female patient is returning to her provider's office with complaints of RLQ pain and heartburn with a temperature of 100.2. The provider performs a detailed history, detailed exam and determines the patient has mild appendicitis. The provider prescribes antibiotics to treat the appendicitis in hopes of avoiding an appendectomy. What are the correct CPT® and ICD- 10 - CM codes for this encounter? a. 99202, R10.31, K b. 99214, K37, R c. 99203, R50.9, R12, R10.31, K
d. 99213, K37 ...ANS: b. 99214, K37, R Rationale: This is an established patient E/M level of service due to the indication she returning to her provider for the visit. Code 99214 is appropriate when two of the three key components are met for an established patient. According to the ICD- 10 - CM guidelines I.B.4., a definitive diagnosis is reported when it has been established. Look in the ICD- 10 - CM Alphabetic Index for Appendicitis which directs you to K37. Guideline I.B.5 indicates any signs or symptoms that would be an integral part of that definitive diagnosis/disease process would not be separately reported. Heartburn is not a symptom commonly seen with appendicitis so we can report this as an additional code, refer to guideline I.B.6. Look in the Alphabetic Index for Heartburn which directs you to R12. Verification in the Tabular List confirms code selections.
7. A 3-year-old presents to the office with his mother for a MMR vaccine. The nurse confrms the order; administers the subcutaneous vaccine; and documents the site, vaccine, lot number, dosage, and date and time. Select the code(s). a. 90460, 90461 x 2, 90707 b. 90471, 90707 c. 90471, d. 90460, 90461, 90707 ...ANS: B. 90471, 90707 Rationale: There is no indication the nurse performed counseling for the vaccine. The correct administration code is
- The vaccine includes measles, mumps, and rubella, reported with 90707. 8. A 45 year-old established female patient is seen today at her provider's office. She is complaining of severe dizziness and feels like the room is spinning. She has had palpitations on and off for the past 12 months. For the ROS, she reports chest tightness and dyspnea but denies nausea, edema or arm pain. She drinks two cups of coffee per day. Her sister has WPW (Wolff-Parkinson- White) syndrome. An extended exam of five organ systems is
A. Emergency Department Services B. Critical Care Services C. Initial Hospital Care D. Inpatient Consultation ...ANS: A. Emergency Department Services. Rationale: When the time for critical care is less than 30, critical care codes are not reported. Code 99291 is used to report when the total time is between 30 and 74 minutes. In this case the ED provider will need to report a code from the Emer- gency Department Services E/M category.
11. A 60 year-old woman is seeking help to quit smoking. She makes an appointment to see Dr. Lung for an initial visit. The patient has a constant cough due to smoking and some shortness of breath. No night sweats, weight loss, night fever, CP, headache or dizziness. She has tried patches and nicotine gum which has not helped. Patient has been smoking for 40 years and smokes 2 packs per day. She has a family history of emphysema. A limited three system exam was performed. Dr Lung discussed, in detail, the pros and cons of medications used to quit smoking. Counseling and education were done for 20 minutes of the 30- minute visit. Prescriptions for Chantix and Tetracycline were given. The patient to follow up in 1 month. A chest X-ray and cardiac work up was ordered. Select the appropriate CPT code(s) for this visit. a. 99203 b. 99202 c. 99203, 99354 d. 99214, 99354 ...ANS: a. 99203 Rationale: Patient is coming to the provider's office for help to quit smoking. The patient is new. The provider documents that 20 minutes of the 30-minute visit was spent counseling the patient. E/M Guidelines identify when time is considered the key or controlling factor to qualify for an E/M service. When counseling and/or coordination of care is more than 50% face to face time in the office
or other outpatient setting, time may be used to determine the level of E/M. The correct code is 99203 based on the total time of the visit which is 30 minutes.
12. A 60-year-old female has pancreatic carcinoma. She is taken to the outpatient surgical center and undergoes placement of Infuse-A-Port for chemotherapy. Fluoroscopic guidance was used to help the physician with the placement of the port. Select the correct code(s). A. 36560, 77001- 26 B. 36560 C. 36561, 77001- 26 D. 36561 ...ANS: C. 36561, 77001- 26 Rationale: Te surgical procedure of the insertion of the port is being performed on a patient that is age 5 years or older. Te Infuse-A-Port is a central venous access device. Guidance can be reported separately with modifer 26 because the provider performs only the professional component. 13. A 75 year-old established patient sees his regular primary care provider for a physical screening prior to joining a group home. He has no new complaints. The patient has an established diagnosis of cerebral palsy and type 2 diabetes and is currently on his meds. A comprehensive history and examination are performed. The provider counsels the patient on the importance of taking his medication and gives him a prescription for refills. Blood work was ordered. PPD was done and flu vaccine given. Patient already had a vision exam. No abnormal historical facts or finding are noted. What CPT® code is reported? a. 99215 b. 99387 c. 99397 d. 99214 ...ANS: c. 99397
c. Develop written standards and policies. d. Restrict employment of ineligible persons. ...ANS: b. Hire an OIG employee to oversee the compliance efforts A comprehensive CIA typically lasts 5 years and includes requirements to: · hire a compliance officer/appoint a compliance committee; · develop written standards and policies; · implement a comprehensive employee training program; · retain an independent review organization to conduct annual reviews; · establish a confidential disclosure program; · restrict employment of ineligible persons; · report overpayments, reportable events, and ongoing investigations/legal proceedings; and · provide an implementation report and annual reports to OIG on the status of the entity's compliance activities. A CRNA performs anesthesia for a tubal ligation on a healthy 35-year- old. The CRNA is working independently. What is the correct code and modifer? A. 00851-QZ-P1 (p65) B. 00860-QZ-P1 (p65) C. 00840-QX-P D. 00860-QX-P1 ...ANS: A. 00851-QZ-P Rationale: From the CPT® Index, look up Anesthesia/tubal ligation. Te CRNA is working without medical direction from an anesthesiologist. Te patient is healthy. A Medicare beneficiary is seen by the cardiovascular surgeon for a consultation in the emergency department. A detailed history,
detailed exam, and MDM of moderate complexity were performed. Which code is reported? a. 99243 b. 99253 c. 99221 d. 99284 ...ANS: d. 99284 With the elimination of payment for consultations, Medicare directs you to report the office and other outpatient and hospital care E/M codes. If a provider is called to the emergency department, Medicare recommends reporting the emergency department E/M codes. A new patient visits the internal medicine clinic today for diabetes, chronic constipation, arthritis and a history of cardiac disease. The provider performs a detailed history, comprehensive exam and a medical decision making of moderate complexity. What CPT® code is reported? a. 99203 b. 99214 c. 99204 d. 99213 ...ANS: a. 99203 Rationale: In the CPT® Index, look for Office and/or Other Outpatient Services/Office Visit/New Patient and you are directed to codes 99201 - 99205. For New Patient visits, all three key components must be met. This service supports a level 3 new patient visit, 99203. A patient is in the hospital after a wedge resection of the left lung due to cancer. He has not been able to keep the lung inflated without a ventilator. A 45-minute team conference between the general surgeon who performed the surgery, the pulmonologist, the oncologist, and the neurologist is held to discuss the best treatment for the patient. The patient and/or patient's family is not present. What CPT® code is reported? a. 99252
C. 105 minutes D. 115 minutes ...ANS: D. 115 minutes Rationale: Te anesthesia time is determined by the anesthesia start and stop times, not the surgical times. A patient undergoes the destruction of three actinic keratosis on 2/1. Te patient returns on 2/13 for evaluation of another suspicious lesion. Which modifer is appropriate? HCPCS DESCRIPTION PCTC IND GLODAYS 17000 Destruct premalg lesion 0 10 17003 Destruct premalg les 2-14 0 ZZZ 17004 Destroy premal lesions 15/> 0 10 17106 Destruction of skin lesions 0 90 17107 Destruction of skin lesions 0 90 17108 Destruction of skin lesions 0 90 a. Modifer 24 b. Modifer 25 c. Modifer 58 d. None ...ANS: D. None Rationale: An actinic keratosis is a premalignant lesion. Te original procedure is reported with 17000, which has a 10 - day global period. Because the date of service for the E/M is outside of the global period, a modifer is not required. A practice contacts an external auditor and explains the practice is billing incident-to services and is not sure they are documenting appropriately, or following the guidelines. What services would the external audit focus on during an audit based on this information? a. Services provided by all providers in the practice.
b. All E/M services provided by all providers in the practice. c. NPP services provided in the practice. d. Surgical services provided by all providers in the practice. ...ANS: C. NPP services provided in the practice.
- Incident-to refers to services provided by NPPs but reported ubder the supervising physicians's provider number. A practice manager runs reports on services billed to Medicare. The reports identify a large number of surgical services reported with modifier 22. As a result, you are hired as an external auditor to review the services identified in the report. What type of audit would you perform? a. A random audit of all surgical services performed. b. A peer review audit on all surgical services. c. A focused audit on evaluation and management services. d. A focused audit on surgical services with modifier 22. ...ANS: d. A focused audit on surgical services with modifier 22. Because an outlier of surgical services reported with modifier 22 has been identified, and this is the reason for the retention of an external auditor, a focused audit of surgical services reported with modifier 22 would be performed. A provider consistently charges a higher level of E/M service than is documented to help cover the cost of his declining practice. Would this be fraud or abuse, and why? a. Abuse; charging one level higher on each visit does not show intent. b. Abuse; the provider's practice is common and therefore would not be considered fraudulent. c. Fraud; any over-coding of services would be considered fraudulent. d. Fraud; the provider intentionally over-coded to gain financially. ...ANS: d. Fraud; the provider intentionally over-coded to gain financially.
Rationale: MUE edits were changed to 1 for bilateral procedures. Medicare requires modifer 50 on bilateral procedures on one line item with one unit. A provider receives notice of a potential audit on lesion removals. Which of the following actions is an example of fraud or misconduct subject to the False Claims Act? a. The provider determines he has forgotten to document the size of one lesion removed and makes an addendum in the patient's chart. b. The provider receives a lab result back and documents in the patient's chart that the lab result indicates a malignant lesion. c. The provider alters all of the medical records for lesion excisions to support the level he reported on the claim. d. The provider reviews his records and determines the documentation supports the claims sent for lesion excisions. ...ANS: c. The provider alters all of the medical records for lesion excisions to support the level he reported on the claim. A provider visits Mr. Smith's home monthly. Today, the provider performs a problem focused history, an expanded problem focused examination and a medical decision making of low complexity. What CPT® code is reported? a. Home visits are no longer reportable. b. 99348 c. 99347 d. 99349 ...ANS: b. 99348 Rationale: In the CPT® Index look for Home Services/Established Patient and you are directed to code range 99347-99350. Two of three key components must be met to support a level of visit for established patient home services. 99348 is the correct code choice. A Qui Tam Relator may receive what type of award for bringing a case in which the government intervenes?
a. 10-15 percent of the money recovered b. 15-25 percent of the money recovered c. 10-15 percent of the total claim amount d. 25-40 percent of the total claim amount ...ANS: b. 15-25 percent of the money recovered A soccer player hits his head during an indoor game and is admitted to observation to watch for head trauma. Admit date/time: 01/21/20XX 8:12 PM Detailed History, Detailed Exam, Low MDM Discharge date/time: 01/22/20XX 8:15 AM Discharge time: 20 minutes What CPT® code(s) is/are reported for the admission and discharge to Observation Care? a. 99221, 99238 b. 99234 c. 99217 d. 99218, 99217 ...ANS: d. 99218, 99217 Rationale: Although the patient was in observation for less than 24 hours, the service covered two dates of service. The Observation care discharge day management code - 99217 - says this code is to be utilized to report all services provided to a patient on discharge from 'observation status if the discharge is on other than the initial date of 'observation status." Initial Observation care is reported with code range 99218-99220. The level of history, exam and medical decision making support level 99218. Code 99217 is reported for Observation care discharge. a. All check boxes must be complete whether normal or abnormal b. Elaboration on abnormal findings c. The patient's height and/or weight to verify there was a face-to- face visit d. A family history of relevant diseases ...ANS: b. Elaboration on abnormal findings
An established 47 year-old patient presents to the provider's office after falling last night in her apartment when she slipped in water on the kitchen floor. She is complaining of low back pain and no tingling or numbness. Provider documents that she has full range motion of the spine, with discomfort. Her gait is within normal limits. Straight leg raising is negative. She requested no medication. It is recommended to use heat, such as a hot water bottle. Provider's Assessment: Lower Back Muscle Strain. What E/M and ICD- 10 - CM codes are reported for this service? a. 99212, S39.012A, W18.30XA, Y92. b. 99213, S33.9XXA, W18.40XD, Y92. c. 99212, S39.012A, W19.XXXD, Y92. d. 99213, S39.012A, W01.0XXA, Y92.030 ...ANS: d. 99213, S39.012A, W01.0XXA, Y92. Rationale: The patient is an established patient. In the CPT® Index look for Established Patient/Office and/or Other Outpatient/Office Visit. You are referred to 99211-99215. An established patient visit requires 2 of 3 key components. The provider documents an Expanded Problem Focused History (brief HPI, pertinent ROS, and no PFSH), a Problem Focused Exam (1 affected organ system, musculoskeletal) and Low MDM (New Problem to examiner, no additional work-up, 0 data points, and acute complicated injury, e.g., simple sprain). Review codes to choose the appropriate level of service. Code 99213 is the correct code. Lower Back Muscle Strain was the provider's diagnosis. In the ICD- 10 - CM Alphabetic Index look for Strain/low back. You are referred to S39.012-. Tabular List shows that a 7 th character is reported. A is reported for the initial encounter. Next go to the External Cause of An established patient presents to the office with a recurrence of bursitis in both shoulders. Examination is limited only to the shoulders in which range of motion is good and full, but he has tenderness in the subdeltoid bursa. Both shoulders were injected in the deltoid bursa with 120mg Depo-Medrol. What CPT® code(s) is/are reported for this visit? a. 99212-25, 20610- 50
b. 99211-25, 20610- 50 c. 99212-25, 20550- 50 d. 20610- 50 ...ANS: d. 20610- 50 Rationale: For this encounter, no additional work in evaluating the patient has been performed to support an E/M service that is significant and separately identifiable from the procedure. Only the procedure is billed. To perform an arthrocentesis, the physician inserts a needle through the skin and into a joint or bursa. A fluid sample may be removed from the joint or fluid may be injected for lavage or drug therapy. In the CPT® Index look for Shoulder/Arthrocentesis. You are referred to codes 20610 and
- Review the code description to verify accuracy. Modifier 50 Bilateral Procedure is attached since both shoulders are injected. CPT ® code 20611 is not correct because it includes ultrasound guidance with permanent recording and reporting. An infant is born six weeks premature in rural Arizona and the pediatrician in attendance intubates the child and administers surfactant in the ET tube while waiting in the ER for the air ambulance. During the 45-minute wait, he continues to bag the critically ill patient on 100 percent oxygen while monitoring VS, ECG, pulse oximetry and temperature. The infant is in a warming unit and an umbilical vein line was placed for fluids and in case of emergent need for medications. How is this coded? a. 99471 b. 99291 c. 99291-25, 31500, 36510, 94610 d. 99471-25, 94610, 36510 ...ANS: c. 99291-25, 31500, 36510, 94610 Based on the 1997 Documentation Guidelines, what is the level of the exam (General Multi-System Exam)? Exam: BP: 118/78 Pulse: 76 T: 98.
