1.)  A provider fails to document the total time spent with a patient during an E/M visit. What should the coder do?

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a) Assign the lowest level E/M code

b) Query the provider for clarification

c) Assume an average time and code accordingly

d) Use the highest-level documented component

 

Answer: b) Query the provider for clarification

Rationale: Coding should always be based on complete and accurate documentation. If time is the deciding factor in E/M code selection, missing time must be clarified.

 

2.)  Which of the following is NOT required in documentation for E/M coding?

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a) Chief complaint

b) Patient’s full name on each page

c) History of present illness

d) Provider's signature

 

Answer: b) Patient’s full name on each page

Rationale: While documentation must identify the patient, each page does not need the full name. However, essential elements like the provider’s signature and chief complaint must be included.

 

3.)  If a coder identifies that a provider is consistently under-documenting services, what is the best     action?

​

a) Report the provider to compliance immediately

b) Code at a higher level based on clinical judgment

c) Provide education on documentation requirements

d) Ignore it and continue coding as documented

 

Answer: c) Provide education on documentation requirements

Rationale: Coding should always reflect documentation. Educating providers helps improve accuracy and compliance.

 

4.)  What is the purpose of modifier -25?

​

a) Identifies a significant, separately identifiable E/M service on the same day as another procedure

b) Indicates a bilateral procedure

c) Shows that a procedure was repeated

d) Distinguishes a professional from a technical service

 

Answer: a) Identifies a significant, separately identifiable E/M service on the same day as another procedure

Rationale: Modifier -25 is used when an E/M service is provided beyond the usual preoperative and postoperative care of a minor procedure.

 

5.)  Which modifier should be used when a procedure is performed bilaterally?

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a) -50

b) -59

c) -51

d) -22

 

Answer: a) -50

Rationale: Modifier -50 indicates that a procedure was performed on both sides of the body during the same operative session.

 

6.)  Modifier -59 is used to indicate what?

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a) A repeat procedure

b) A significant, separately identifiable service

c) A distinct procedural service

d) An increased procedural complexity

 

Answer: c) A distinct procedural service

Rationale: Modifier -59 is used when two services that are normally bundled together were performed independently in separate locations or times.

 

7.)  A provider documents a detailed history and detailed exam but the medical decision-making is low. What level of E/M code should be assigned?

​

a) The highest level documented

b) The lowest level documented

c) Average of all components

d) Based only on time

 

Answer: b) The lowest level documented

Rationale: For most E/M codes, the final code is determined by the lowest of the three key components (history, exam, and medical decision-making).

 

8.)  Which factor is NOT considered when selecting an E/M level in 2023 outpatient guidelines?

​

a) Time

b) Medical decision-making

c) History and exam complexity

d) Patient’s insurance coverage

 

Answer: d) Patient’s insurance coverage

Rationale: Insurance coverage does not affect E/M code selection. The correct code is based on medical necessity, decision-making, and/or time.

 

9.) Upcoding is considered which type of violation?

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a) A compliance issue with no penalties

b) A minor documentation error

c) Fraudulent activity under the False Claims Act

d) A coding mistake with no consequences

 

Answer: c) Fraudulent activity under the False Claims Act

Rationale: Upcoding (billing for a higher level of service than provided) is considered fraud and can result in significant legal penalties.

 

10.)  A coder notices a provider frequently bills a level 5 E/M service for routine visits. What should the coder do?

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a) Report the provider to Medicare

b) Query the provider for justification

c) Change the code to a lower level without consulting the provider

d) Ignore it

 

Answer: b) Query the provider for justification

Rationale: Before reporting or changing codes, the coder should first ask the provider for additional documentation to justify the coding.

 

11.)  A minor procedure with zero-day global period is performed, and the provider also bills an E/M visit. What should be done?

​

a) Append modifier -25 to the E/M code

b) Code only the procedure

c) Code only the E/M visit

d) Append modifier -57

 

Answer: a) Append modifier -25 to the E/M code

Rationale: Modifier -25 ensures payment for a significant, separately identifiable E/M service on the same day as a minor procedure.

 

12.)  A coder sees that an assistant surgeon was involved in a procedure. What modifier should be added to their services?

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a) -80

b) -81

c) -82

d) -59

 

Answer: a) -80

Rationale: Modifier -80 indicates that an assistant surgeon provided services during surgery.

 

13.)  Which CPT code is used for an Initial Medicare Annual Wellness Visit (AWV)?

​

a) 99397

b) G0438

c) G0439

d) 99214

 

Answer: b) G0438

Rationale: G0438 is for the initial AWV, while G0439 is for subsequent AWVs.

 

14.)  A patient presents for their Medicare Annual Wellness Visit (AWV) but also has a new complaint requiring evaluation. How should this be coded?

​

a) Bill only the AWV

b) Bill the AWV and an E/M visit with modifier -25

c) Bill only the E/M visit

d) Bill the AWV with modifier -59

 

Answer: b) Bill the AWV and an E/M visit with modifier -25

Rationale: Modifier -25 is needed to indicate a separately identifiable E/M service.

 

15.)  A 40-year-old patient presents for a comprehensive preventive visit, and no problems are addressed. Which code is appropriate?

​

a) 99385

b) 99396

c) 99213

d) G0438

 

Answer: b) 99396

Rationale: CPT 99396 is used for a comprehensive preventive visit for an established patient aged 40-64.

 

16.)  If a provider performs a preventive visit (99396) and also addresses an acute condition requiring management, what should be done?

​

a) Bill only the preventive visit

b) Bill the preventive visit and an E/M code with modifier -25

c) Bill two preventive visits

d) Add modifier -59

 

Answer: b) Bill the preventive visit and an E/M code with modifier -25

Rationale: An additional E/M code can be billed if a significant separate issue is addressed.

 

17.)  Which of the following is NOT typically included in a Medicare Annual Wellness Visit (AWV)?

​

a) Review of health risks

b) Cognitive assessment

c) Comprehensive physical exam

d) Screening for depression

 

Answer: c) Comprehensive physical exam

Rationale: Medicare AWVs do not include a head-to-toe physical exam.

 

18.)  Hospital Procedures & Inpatient Coding

A surgeon performs a total knee replacement. Which modifier is used if another surgeon assists?

​

a) -80

b) -51

c) -25

d) -59

 

Answer: a) -80

Rationale: Modifier -80 indicates an assistant surgeon.

 

19.)  A patient is admitted with pneumonia and treated with IV antibiotics. Which code type is used?

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a) CPT

b) HCPCS

c) ICD-10-CM

d) ICD-10-PCS

 

Answer: c) ICD-10-CM

Rationale: ICD-10-CM is used for diagnosis coding in inpatient and outpatient settings.

 

20.)  A provider performs a bedside bronchoscopy in the ICU. How should this be coded?

​

a) Report only the ICU E/M code

b) Assign both a procedure code and an E/M visit code

c) Report only the bronchoscopy CPT code

d) Use modifier -25 on the E/M visit

 

Answer: c) Report only the bronchoscopy CPT code

Rationale: When a procedure is performed, the E/M code is usually not separately billable unless significant additional work was done.

 

21.)  What is the correct CPT code for a laparoscopic appendectomy?

​

a) 44950

b) 44970

c) 44960

d) 47562

 

Answer: b) 44970

Rationale: 44970 is the CPT code for laparoscopic appendectomy.

 

22.)  A patient undergoes a screening colonoscopy but a polyp is removed during the procedure. What is the correct coding approach?

​

a) Bill only the screening colonoscopy code

b) Bill the polyp removal code with modifier -33

c) Bill the polyp removal code and the screening code with modifier -PT

d) Bill the screening code with modifier -52

 

Answer: c) Bill the polyp removal code and the screening code with modifier -PT

Rationale: Modifier -PT indicates a screening procedure that became therapeutic.

 

23.)  A hospitalist sees a patient for the first time during an inpatient admission. What code range applies?

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a) 99202-99205

b) 99221-99223

c) 99231-99233

d) 99281-99285

 

Answer: b) 99221-99223

Rationale: These codes are used for initial inpatient encounters.

 

24.)  A coder finds that a provider frequently bills level 3 inpatient visits but documentation supports level 2. What should be done?

​

a) Adjust the code to level 2

b) Report the provider to compliance immediately

c) Query the provider for clarification

d) Continue coding as level 3

 

Answer: c) Query the provider for clarification

Rationale: Documentation should support the billed service. If unclear, a query is the best course of action.

 

25.)  A surgeon performs a hernia repair and also drains an abscess in the same session. What should be done?

​

a) Bill only the hernia repair

b) Bill the hernia repair and abscess drainage with modifier -59

c) Bill both procedures with modifier -51

d) Bill the abscess drainage separately without modifiers

 

Answer: b) Bill the hernia repair and abscess drainage with modifier -59

Rationale: Modifier -59 is used when procedures are distinct and separately performed.

 

26.)  A provider performs a Medicare Annual Wellness Visit (AWV) and addresses a new acute issue requiring medical decision-making. How should this be coded?

​

a) Bill only the AWV (G0438 or G0439)

b) Bill both the AWV and an E/M visit with modifier -25

c) Bill only an E/M visit

d) Bill the AWV with modifier -59

 

Answer: b) Bill both the AWV and an E/M visit with modifier -25

Rationale: Modifier -25 is required when a significant, separately identifiable E/M service is performed on the same day as an AWV.

 

27.)  Which of the following services is covered under a Medicare Annual Wellness Visit (AWV)?

 

a) A comprehensive physical exam

b) A detailed musculoskeletal assessment

c) Personalized prevention plan and health risk assessment

d) Evaluation and management of chronic conditions

 

Answer: c) Personalized prevention plan and health risk assessment

Rationale: AWVs focus on preventive care and do not include a head-to-toe physical exam or management of chronic conditions.

 

28.)  A Medicare patient receives a G0439 Annual Wellness Visit, and the provider also addresses poorly controlled hypertension. How should this be reported?

 

a) Report only G0439

b) Report G0439 and 99213 with modifier -25

c) Report G0439 and 99214 without any modifiers

d) Report only the E/M code

​

Answer: b) Report G0439 and 99213 with modifier -25

Rationale: The E/M visit must be separately documented and should include modifier -25 to indicate it is a distinct service.

 

29.)  Which statement is TRUE regarding an Initial Preventive Physical Examination (IPPE, G0402) and an AWV?

​

a) They are the same service and billed interchangeably

b) IPPE is a one-time service, while AWVs are performed annually

c) Both services require modifier -25 when billed together

d) AWVs must include a full physical exam

 

Answer: b) IPPE is a one-time service, while AWVs are performed annually

Rationale: The IPPE (G0402) is only covered once within the first 12 months of Medicare enrollment, while AWVs (G0438/G0439) are covered yearly.

 

30.)  A patient has a Medicare Annual Wellness Visit (G0438) and requests a full physical exam. What should the provider do?

​

a) Perform and bill both the AWV and a preventive visit (99397)

b) Explain that AWV does not include a comprehensive physical exam

c) Bill only the preventive visit and not the AWV

d) Use modifier -25 on the AWV

 

Answer: b) Explain that AWV does not include a comprehensive physical exam

Rationale: AWVs focus on prevention and do not include a hands-on physical exam like a commercial insurance preventive visit.

 

31.)  When billing a problem-oriented E/M visit with an AWV, which documentation is required for the E/M service?

​

a) Chief complaint, history, exam, and medical decision-making related to the problem

b) A summary of preventive care items

c) A comprehensive physical exam

d) Documentation is not needed if an AWV is performed

 

Answer: a) Chief complaint, history, exam, and medical decision-making related to the problem

Rationale: The E/M visit must be separately identifiable and documented appropriately.

 

32.)  What is the difference between a Subsequent Annual Wellness Visit (G0439) and a preventive medicine visit (99397)?

​

a) G0439 is covered by Medicare, while 99397 is used for commercial insurance

b) G0439 includes a full physical exam

c) 99397 includes only a review of history and medications

d) There is no difference

 

Answer: a) G0439 is covered by Medicare, while 99397 is used for commercial insurance

Rationale: Medicare AWVs do not include comprehensive physical exams, whereas preventive visits under CPT (99397) do.

 

33.)  A Medicare patient is scheduled for an AWV but also needs medication adjustments for diabetes and hypertension. How should this be coded?

​

a) Bill G0439 and the appropriate E/M code with modifier -25

b) Bill only the AWV

c) Bill the AWV with modifier -59

d) Bill only an E/M visit

 

Answer: a) Bill G0439 and the appropriate E/M code with modifier -25

Rationale: When a provider manages medical problems separately from the AWV, the additional E/M service must be reported with modifier -25.

 

34.)  Which of the following is NOT a required element of a Medicare Annual Wellness Visit?

​

a) Health risk assessment

b) Depression screening

c) Ankle-brachial index test

d) Cognitive assessment

 

Answer: c) Ankle-brachial index test

Rationale: An AWV includes screenings like cognitive assessment and depression screening but does not require specific diagnostic tests like ABI.

 

35.)  Which modifier should be appended to a problem-oriented E/M service when billed with a Medicare AWV?

​

a) -59

b) -51

c) -25

d) -26

 

Answer: c) -25

Rationale: Modifier -25 is used to indicate a separately identifiable E/M service performed on the same day as a preventive visit.

 

36.) If a patient has an AWV and the provider orders routine lab work, how should the lab tests be billed?

 

a) As part of the AWV with no separate billing

b) Separately using the appropriate lab CPT codes

c) Using modifier -25 on the AWV

d) With modifier -59 on the lab codes

 

Answer: b) Separately using the appropriate lab CPT codes

Rationale: Medicare does not include lab tests in the AWV; they must be billed separately.

 

37.)  A Medicare Annual Wellness Visit (AWV) is conducted via telehealth. Which code should be used?

​

a) G0438 or G0439 with modifier -95

b) 99212-99215 with modifier -GT

c) G0402 with modifier -25

d) G0438-G0439 without any modifier

 

Answer: a) G0438 or G0439 with modifier -95

Rationale: Modifier -95 is used for services provided via telehealth to indicate a synchronous visit.

 

38.)   Which of the following is a requirement for a telehealth AWV?

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a) The patient must be at an originating site like a rural health clinic

b) The patient must use audio-only communication

c) The visit must include a personalized prevention plan and health risk assessment

d) The provider must perform a hands-on physical exam

 

Answer: c) The visit must include a personalized prevention plan and health risk assessment

Rationale: A telehealth AWV must include all required elements of an in-person AWV, except for physical examination.

 

39.)  What should a provider do if an attempted telehealth AWV is incomplete due to a patient’s inability to participate fully?

​

a) Bill the full AWV regardless of completion

b) Document the issue and reschedule or adjust coding as appropriate

c) Use modifier -52 for reduced services

d) Bill a standard office visit code instead

 

Answer: b) Document the issue and reschedule or adjust coding as appropriate

Rationale: Incomplete AWVs should be documented and, if necessary, rescheduled to ensure proper coding and compliance.

 

40.)  A patient with multiple chronic conditions completes an AWV and is enrolled in a chronic care management (CCM) program. How should this be coded?

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a) Bill only the AWV (G0438/G0439)

b) Bill the AWV and CCM codes (99490 or 99491) separately

c) Bill CCM codes only, as they include AWV components

d) Use modifier -25 on the CCM code

 

Answer: b) Bill the AWV and CCM codes (99490 or 99491) separately

Rationale: AWV and CCM services are separately reimbursable when appropriately documented.

 

41.)  Which of the following is required for billing Chronic Care Management (CCM) services after an AWV?

​

a) The patient must have at least one chronic condition

b) The provider must spend at least 20 minutes per month managing the patient’s conditions

c) The patient must be seen in-person at least every three months

d) The CCM service must be provided on the same date as the AWV

 

Answer: b) The provider must spend at least 20 minutes per month managing the patient’s conditions

Rationale: CCM services (99490) require at least 20 minutes of non-face-to-face care coordination for patients with multiple chronic conditions.

 

42.)  What is the purpose of billing a Medicare Annual Wellness Visit (AWV) before initiating Chronic Care Management (CCM)?

​

a) To ensure the patient understands their preventive care plan

b) To replace the need for additional E/M visits

c) To bill both services on the same date for increased reimbursement

d) To satisfy Medicare’s requirement for an in-person visit before CCM enrollment

 

Answer: d) To satisfy Medicare’s requirement for an in-person visit before CCM enrollment

Rationale: Medicare requires an in-person visit, which can be an AWV, within 12 months before initiating CCM services.

 

43.)  A provider documents an Annual Wellness Visit (AWV) but also discusses a new acute problem without separate documentation. What should the coder do?

​

a) Bill only the AWV

b) Bill the AWV and an E/M visit without a modifier

c) Query the provider for additional documentation before adding an E/M code

d) Bill only an E/M visit and ignore the AWV

 

Answer: c) Query the provider for additional documentation before adding an E/M code

Rationale: A separately identifiable E/M service requires clear documentation; otherwise, only the AWV should be billed.

 

44.)  A coder notices that a provider frequently bills an E/M visit with an AWV but rarely documents separate issues. What should be done?

​

a) Report the provider for fraud immediately

b) Educate the provider on documentation requirements for separately billed E/M services

c) Automatically remove the E/M charge each time

d) Ignore the issue and continue coding as documented

 

Answer: b) Educate the provider on documentation requirements for separately billed E/M services

Rationale: Providers must understand that an E/M visit billed with an AWV requires clear documentation of separate services.

 

45.)  Which of the following documentation deficiencies would cause an AWV claim to be denied?

​

a) Missing health risk assessment

b) Lack of a physical exam

c) Documentation of preventive screenings

d) Signed provider attestation

 

Answer: a) Missing health risk assessment

Rationale: The health risk assessment is a required component of an AWV, and its absence may lead to claim denial.

 

46.)  A provider mistakenly bills an AWV for a patient who already received one within the same calendar year. What will likely happen?

​

a) Medicare will pay for both visits

b) The second claim will be denied

c) The claim will be adjusted to a regular E/M visit

d) The patient will be responsible for the cost

 

Answer: b) The second claim will be denied

Rationale: Medicare covers only one AWV per calendar year, and duplicate billing results in denial.

 

47.) When billing an E/M visit with an AWV, which of the following is NOT a valid reason for the E/M visit?

​

a) New acute issue requiring evaluation

b) Medication review and refill

c) Chronic condition requiring management beyond preventive care

d) Review of patient’s immunization history

 

Answer: d) Review of patient’s immunization history

Rationale: Immunization review is part of the AWV and does not justify a separate E/M service.

 

48.) Which of the following would be a compliance risk when coding AWVs?

​

a) Billing an AWV without all required elements documented

b) Billing an E/M visit with an AWV for a separately documented new problem

c) Adding a diagnosis code for a patient’s chronic condition

d) Providing a preventive screening discussion during the AWV

 

Answer: a) Billing an AWV without all required elements documented

Rationale: AWVs require documentation of all required elements, and missing components can lead to claim denials or compliance issues.

 

49.)  What should a coder do if an AWV note includes only a brief health summary without a prevention plan?

​

a) Bill a regular E/M visit instead

b) Query the provider for missing required elements

c) Submit the claim as is

d) Add generic preventive care recommendations to the note

 

Answer: b) Query the provider for missing required elements

Rationale: The AWV must include a personalized prevention plan. Missing elements require clarification before billing.

 

50.) Which of the following is the best practice when documenting an E/M visit with an AWV?

​

a) Combine all documentation into one note

b) Clearly separate the AWV and E/M visit documentation

c) Use a generic template for all visits

d) Bill both services without reviewing documentation

 

Answer: b) Clearly separate the AWV and E/M visit documentation

Rationale: Proper documentation should distinguish preventive care from problem-oriented care to justify separate billing.

 

51.) 65-year-old male patient is diagnosed with hypertension during a routine office visit. The provider documents "essential hypertension" without any complications or associated conditions. What is the correct ICD-10-CM code for this diagnosis?

​

a) I15.0 - Renovascular hypertension
b) I11.0 - Hypertensive heart disease with heart failure
c) I10 - Essential (primary) hypertension
d) I12.9 - Hypertensive chronic kidney disease with stage 1-4 CKD or unspecified CKD

 

Answer: c) I10 - Essential (primary) hypertension

Rationale: The ICD-10-CM code I10 is used for essential (primary) hypertension, which is high blood pressure without any specified secondary cause or associated complications. The provider did not document any heart or kidney disease linked to the hypertension, so codes from categories I11 (hypertensive heart disease), I12 (hypertensive kidney disease), or I15 (secondary hypertension) would not be appropriate. Proper documentation review ensures accurate coding and avoids unnecessary specificity or errors in reporting.