AAPC Certified Professional Coder (CPC) — All Questions

Under the current (2021 and later) office/outpatient E/M guidelines, how is the level of service selected?

• a.By the number of organ systems reviewed in the review of systems, tallied against the documented chief complaint
• b.By the severity of the chief complaint alone
• c.By counting history bullets and examination elements; the 2021-and-later office visit level is still tabulated from the number of documented history and exam findings, and neither total time nor medical decision making may drive the selection
• d.By either the total time spent on the date of the encounter OR the level of medical decision making (MDM)✓

The 2021 overhaul removed history and exam as the drivers of office/outpatient visit level. Coders now choose based on MDM or on total time on the date of service (face-to-face plus non-face-to-face work by the physician/QHP). History and exam are still documented for clinical care but no longer determine the code.

The level of medical decision making (MDM) is determined by three elements. Which set correctly names them?

• a.Number and complexity of problems addressed; amount and/or complexity of data reviewed and analyzed; and risk of complications/morbidity of management✓
• b.Coordination of care, counseling, and the nature of the presenting problem; these three elements are what CPT weighs to arrive at the level of medical decision making, and the complexity of data or the risk of the management options are treated as supporting factors only
• c.History, examination, and time
• d.Chief complaint, review of systems, and past/family/social history

MDM is scored across three columns — problems addressed, data reviewed/analyzed (labs, notes, independent interpretation, discussion with other providers), and risk. The overall level is set by meeting or exceeding two of the three elements. The older history/exam bullets and the 1995/1997 audit approach no longer apply to office visits.

When is modifier -25 correctly appended to an E/M service?

• a.When a significant, separately identifiable E/M is performed by the same provider on the same day as a minor procedure or other service with a global period✓
• b.When reporting a preventive medicine (wellness) visit
• c.When a physician requests a consultation from a specialist; modifier -25 is the mechanism that flags an interprofessional consultation request, and it is appended to the requesting provider's E/M whenever advice is sought from another physician on the same calendar date
• d.When the E/M is the only service billed that day

Modifier -25 unbundles an E/M that stands on its own from a same-day procedure that carries its own inherent pre/post work. The E/M must be above and beyond the usual work associated with the procedure and supported by separate documentation. It is never used simply to get an office visit paid when no other service was performed.

Which modifier identifies the E/M service at which the decision to perform a major (90-day global) surgery was made?

• a.-24 (unrelated E/M during a postoperative period)
• b.-57 (decision for surgery)✓
• c.-25 (significant, separately identifiable E/M on the day of a procedure)
• d.-58 (staged procedure)

Modifier -57 marks the E/M visit (the day before or day of a major/90-day-global surgery) at which the surgeon decided to operate; without it, that visit may be denied as part of the global package. Do not confuse it with -25, which is used with MINOR procedures (0/10-day global). Matching -57 to major surgery and -25 to minor procedures is a frequent exam distinction.

A patient received professional (face-to-face) services from a physician of the same specialty in the same group practice within the prior three years. For E/M coding, this patient is:

• a.A new patient, because each visit is evaluated on its own
• b.A new patient if a different diagnosis is addressed
• c.An established patient✓
• d.A consultation

The new-vs-established test is the three-year rule: a patient is 'new' only if they have not received a professional service from that provider — or another provider of the exact same specialty/subspecialty in the same group — within the past three years. Here the prior visit was within three years and same specialty/group, so the patient is established. The diagnosis addressed does not change this.

Under the 2021-and-later office/outpatient E/M rules, the 'total time' used to select the level includes:

• a.Only face-to-face time spent with the patient
• b.Time spent by clinical staff (nurses/medical assistants) in addition to the physician
• c.All qualifying face-to-face and non-face-to-face time personally spent by the physician/QHP on the date of the encounter✓
• d.Time spent on any day within the same week as the visit

Total time now counts the physician's/QHP's own face-to-face AND non-face-to-face work performed on the date of the encounter — chart review, ordering tests, documenting, care coordination, and counseling. It does NOT include staff time or work done on other days. Understanding what counts toward time prevents inflating the visit level.

When the physician's total time exceeds the time required for the highest-level office/outpatient visit, the additional time is captured with:

• a.Modifier -22 (increased procedural services)
• b.A prolonged services add-on code✓
• c.A higher-level new-patient code chosen without regard to time
• d.A critical care code

Once documented time exceeds the threshold of the highest-level office visit, the extra time is reported with the appropriate prolonged services add-on code (reported in addition to the highest-level E/M). Modifier -22 is for surgical/procedural work, not E/M time, and you cannot simply jump to an unrelated higher code. Prolonged-services rules reward the additional cognitive time appropriately.

For payers that still recognize consultation codes, a service qualifies as a consultation only when there is:

• a.A request from another provider, the consultant's opinion/advice rendered, and a written report back to the requesting provider (the 'three Rs')✓
• b.Any visit to a specialist, regardless of who initiated it
• c.A patient self-referral for a second opinion
• d.A transfer of the patient's complete care to the specialist; a consultation is properly reported whenever a patient's ongoing management is handed off, and the transfer of care itself satisfies the requirement without any written report back to the requesting provider

A true consultation requires the three Rs: a Request for opinion/advice from another physician or appropriate source, the consultant Rendering that opinion (and any services), and a written Report communicated back to the requester. If the specialist simply assumes ongoing management, or the patient self-refers, it is not a consultation and an office/outpatient E/M is used instead.

Which statement about critical care E/M coding is correct?

• a.Each 15-minute increment is reported separately regardless of total time; critical care is billed in discrete quarter-hour units, and the coder tallies one unit per 15 minutes of care with no single base code capturing the first block of time
• b.It is reported based on the total time spent caring for the critically ill patient, and certain bundled ancillary services are not separately billable✓
• c.It may only be reported in the emergency department
• d.It is selected by medical decision making rather than time

Critical care is time-based: the first code covers a defined block of time and an add-on captures each additional block. CPT bundles several services into critical care (e.g., certain vascular access, blood gas interpretation, ventilator management, and specified data reviews), which cannot be billed separately during the critical care time. It may be provided in any location where the patient is critically ill, not just the ED.

Emergency department (ED) E/M codes differ from office E/M codes in that they:

• a.Are always selected by the total time the physician spends in the emergency department, counting both bedside and coordination time
• b.Do not distinguish new from established patients and are not leveled by time (they are selected by medical decision making)✓
• c.Distinguish new from established patients; emergency department E/M codes, like office codes, branch on whether the patient is new or established to the group, so the coder must verify a three-year prior-encounter history before selecting the ED level
• d.Require modifier -57 on every claim

ED E/M codes make no new-vs-established distinction because emergency care is provided regardless of prior relationship, and they are not chosen by time (time is not a factor in the ED code family). The level is driven by medical decision making. Knowing which E/M families allow a time basis — and which do not — is essential to correct leveling.

During an annual preventive medicine visit, the provider also evaluates and manages a significant, separate new problem. How is this reported?

• a.Only the preventive medicine code; when a separate significant problem is addressed at a wellness visit its work is folded into the comprehensive preventive service, so a problem-oriented E/M with modifier -25 is not additionally reportable on the same date
• b.Only the problem-oriented E/M code
• c.Both the preventive medicine service and a problem-oriented office/outpatient E/M code, with modifier -25 on the problem-oriented visit✓
• d.A single combined code

When a significant, separately identifiable problem is addressed at a wellness visit, both services are reported: the preventive medicine code plus the appropriate office/outpatient E/M for the problem, with modifier -25 on the problem visit to show it stands apart from the preventive service. The problem work must be documented separately and be significant — not just an incidental note.

Which modifier indicates a synchronous, real-time telemedicine service delivered via interactive audio and video?

• a.-59 (distinct procedural service)
• b.-95 (synchronous telemedicine service via real-time audio-video)✓
• c.-52 (reduced services)
• d.-26 (professional component)

Modifier -95 identifies a service on the approved telemedicine list that was furnished in real time using interactive audio-and-video telecommunications. It signals that an otherwise in-person service was delivered via live telehealth. It is not used for audio-only encounters or for the professional/technical split, which are handled by other modifiers.

Under the 2023 E/M revisions, hospital inpatient and observation care services are:

• a.Selected by MDM or total time on the date, with observation care merged into the inpatient/observation code families✓
• b.Still leveled by history and exam bullets; under the 2023 revisions inpatient and observation services continue to be scored by counting documented history and examination elements, and medical decision making or total time may not be used to select the level
• c.Always time-based only, so an inpatient or observation level may be chosen solely from the total minutes documented and never from decision making
• d.No longer reportable

The 2023 revisions extended the office-visit approach (choose by medical decision making or total time) to hospital inpatient and observation care, and observation services were merged into the same inpatient/observation code families. The trap is applying the retired 1995/1997 history-and-exam bullet scoring, which no longer determines these codes.

In a facility setting, a 'split (or shared)' E/M visit is one in which:

• a.Two unrelated groups split a fee
• b.The patient is seen on two separate days
• c.A resident works entirely unsupervised and the attending later co-signs; a split or shared visit in the facility setting is defined by resident-to-teaching-physician cosignature, and the substantive-portion rule between a physician and a nonphysician practitioner has no application to it
• d.A physician and a nonphysician practitioner in the same group each perform part of the same E/M, reported by whoever performed the substantive portion✓

A split/shared visit occurs when a physician and a nonphysician practitioner (NPP/QHP) in the same group jointly provide a single E/M encounter; the visit is billed by the professional who performed the substantive portion (as defined by current rules). The trap is confusing it with a two-day encounter or two separate groups — split/shared is one encounter, one group, two clinicians.

Prolonged service add-on codes are:

• a.Reportable with any level of E/M service, so a prolonged-service add-on may attach even to the lowest-level visit when extra time is spent
• b.Used for procedures
• c.A replacement for the primary E/M code; a prolonged-service code is reported instead of the base office visit once the encounter runs long, standing in for the primary E/M rather than being added onto it
• d.Reported only once the highest-level primary E/M time threshold is met and additional qualifying time is documented✓

Prolonged-services add-on codes may be reported only after the time threshold of the highest-level primary E/M in that category is met or exceeded, capturing the extra qualifying time in defined increments. The trap is appending prolonged services to a lower-level visit or using them for procedural (non-E/M) time, neither of which is correct.

During the 90-day global period of a knee surgery, the same surgeon evaluates the patient for an unrelated new problem (a skin rash). The E/M is reported with:

• a.-25 (significant, separately identifiable E/M on the day of a procedure)
• b.-24 (unrelated E/M service during the postoperative period)✓
• c.-79 (unrelated procedure by the same physician performed during the postoperative period)
• d.-57 (decision for surgery, appended to the E/M at which major surgery was decided upon)

Modifier -24 identifies an unrelated E/M service performed by the same physician during a postoperative global period, so it is not bundled into the surgical package. It differs from -79 (an unrelated procedure in the global period) and -25 (a same-day E/M with a minor procedure). The trap is -24 (unrelated E/M) versus -79 (unrelated procedure).

Under CPT E/M rules, a patient is classified as 'new' when the patient:

• a.Has never physically been to this particular practice's office location before, regardless of which physician, specialty, or group the patient may have seen elsewhere within the past three years
• b.Has NOT received a face-to-face professional service from the physician (or another physician of the same specialty/subspecialty in the same group) within the past three years✓
• c.Is seeing any new staff member for the first time
• d.Has not been seen within the past twelve months

The new/established distinction turns on the three-year rule: a patient is 'new' if no face-to-face professional service was provided by the same physician OR another physician of the exact same specialty and subspecialty in the same group practice within the prior three years. Otherwise the patient is 'established.'

In selecting an office/outpatient E/M level by medical decision making, prescription drug management is generally classified at what risk level?

• a.High risk
• b.Moderate risk of complications✓
• c.Minimal risk
• d.Low risk

Under the 2021-and-later MDM guidelines, prescription drug management is an example element of MODERATE risk in the 'risk of complications' column. High risk includes elements such as drug therapy requiring intensive toxicity monitoring or a decision regarding hospitalization. The overall level still requires meeting 2 of the 3 MDM elements.

When selecting an office/outpatient E/M level by MDM, the overall level is determined by:

• a.Averaging the three MDM elements
• b.Meeting or exceeding the requirements in at least two of the three MDM elements✓
• c.Meeting all three MDM elements at the same level
• d.Meeting any one MDM element

Office/outpatient MDM level is set when two of the three elements — problems addressed, data reviewed/analyzed, and risk — reach a given level. The two-of-three rule prevents a single element from driving the code and encourages complete documentation of the encounter's complexity.

For office/outpatient E/M selected by total time, which activity may be counted?

• a.Time spent by clinical staff performing the patient intake and rooming, which may be added to the physician's own time on the date of service
• b.Travel time to the facility
• c.Time on a separate calendar day before the visit
• d.Time the physician/QHP personally spends on care activities on the date of the encounter, including reviewing results and documenting✓

Total time includes the physician's/QHP's own face-to-face and non-face-to-face work on the date of service — reviewing history/data, ordering, counseling, and documenting. It excludes clinical-staff time and time on other dates. Only qualifying provider time on the encounter date counts toward the time threshold.

Critical care time (99291/99292) is reported based on:

• a.The number of organ systems examined
• b.Only continuous, uninterrupted bedside time, since critical care minutes must be spent physically and continuously at the bedside and can never be aggregated across separate periods of the same calendar day
• c.The total time the physician spends devoted to the critically ill patient on a given date, which may be continuous or aggregated, excluding time for separately reportable procedures✓
• d.A flat per-visit rate regardless of time

Critical care is time-based: sum the physician's time devoted to the critically ill/injured patient on that date (bedside and on the unit doing directly related work), which need not be continuous. Time spent on separately billable procedures is excluded, and the first hour requires meeting the initial-code time threshold.

Emergency department E/M codes differ from office E/M codes in that ED codes:

• a.Are always selected by total time
• b.Use the same codes as office visits
• c.Have no new-versus-established patient distinction and are not selected by time✓
• d.Require a preventive-medicine component

ED E/M codes apply to all patients regardless of new/established status because the ED provides episodic care, and there is no typical time associated for time-based selection — level is chosen by MDM (per the 2023 revisions). This structural difference distinguishes ED coding from office/outpatient coding.

Under the 2023 E/M revisions, hospital observation care is:

• a.Reported with a separate, distinct observation-only code set that remains parallel to but distinct from the inpatient admission codes
• b.Selected only by history and exam bullets
• c.No longer reportable at all
• d.Merged with inpatient hospital care into a single set of codes selected by MDM or total time✓

The 2023 CPT changes deleted the standalone observation code set and merged observation into the hospital inpatient and observation care codes, selected by MDM or total time. This aligned the inpatient/observation family with the 2021 office-visit methodology.

A prolonged office/outpatient service add-on code (used with the highest-level office visit) is reported only when:

• a.Any additional face-to-face minutes occurred
• b.The visit was selected using medical decision making and the problem addressed was of high severity requiring extra physician effort
• c.The visit was selected using total time and that time exceeds the primary code's time by the required increment✓
• d.The patient was seen after normal business hours

The office/outpatient prolonged add-on (e.g., 99417, or Medicare's G2212) is used only when the base level was chosen by TIME and the total time exceeds the threshold of the highest-level visit by the specified increment. It cannot be added when the level was chosen by MDM, nor for time below the required extra minutes.

During an annual preventive-medicine visit, the provider also fully evaluates and manages a significant, separate problem. The correct approach is to:

• a.Combine both into one higher-level code
• b.Report only the problem-oriented office E/M code, since the significant separate problem absorbs and replaces the preventive service for that date
• c.Report only the preventive-medicine code
• d.Report the preventive-medicine code AND a problem-oriented office E/M code with modifier -25 appended to the problem visit✓

When a significant, separately identifiable problem-oriented E/M is performed at a preventive visit, both services are reported: the preventive-medicine code plus the appropriate office/outpatient E/M with modifier -25. The problem work must be above and beyond the routine preventive service and separately documented.

For payers that still recognize consultations, a defining requirement of a consultation is that:

• a.No documentation of the request is necessary
• b.There is a request and reason from another appropriate source, and the consultant renders a written report back to the requesting provider✓
• c.The patient self-refers for a second opinion without any request
• d.The consultant assumes complete ongoing management of the patient's care at the visit and communicates a report back only if time permits afterward

A billable consultation requires a request (and reason) from another physician/appropriate source, the consultant's opinion/advice, and a written report communicated back to the requester. If the consultant assumes management or the patient self-refers, it is generally not a consultation. (Medicare no longer recognizes consultation codes.)

Modifier -57 (decision for surgery) differs from modifier -25 in that -57 is appended to an E/M when the decision made is for:

• a.A minor procedure with a 0- or 10-day global period
• b.A diagnostic laboratory test
• c.A major surgery (90-day global) performed the day of or the day before the procedure✓
• d.A preventive-medicine service

Modifier -57 flags the E/M at which the decision to perform a MAJOR (90-day global) surgery was made, on the day of or day before surgery. Modifier -25 is used for a significant, separate E/M on the same day as a MINOR procedure (0-/10-day global). Matching the modifier to the global period is essential.

Preventive-medicine (wellness) E/M codes are selected based on:

• a.The level of medical decision making
• b.The total time spent counseling only
• c.The patient's age and whether the patient is new or established✓
• d.The number of chronic conditions managed

Preventive-medicine service codes are stratified by patient age group and new/established status, reflecting age-appropriate history, exam, counseling, and risk-factor reduction. They are not selected by MDM or time like problem-oriented office visits; a separate problem E/M may be added with modifier -25 when warranted.

Under the office/outpatient MDM guidelines, a decision regarding hospitalization or escalation of care is an example element of what level of risk?

• a.Moderate risk
• b.Low risk
• c.High risk✓
• d.Minimal risk

A decision regarding hospitalization (or de-escalation because of poor prognosis) is a HIGH-risk element in the MDM 'risk' column, along with drug therapy requiring intensive monitoring for toxicity. Prescription drug management is moderate; over-the-counter drug management is low. Correct risk leveling supports the overall MDM level.

In the office/outpatient MDM 'amount and complexity of data' element, which counts as an independent category of data?

• a.The physician's independent interpretation of a test that was not separately reported by that physician✓
• b.Prescribing a routine medication
• c.Ordering and personally billing a single laboratory test, which counts as an independent category of data in the MDM data element
• d.Documenting the chief complaint

The data element credits independent interpretation of a test (not separately reported by the interpreting physician), review of external notes/tests, ordering/reviewing tests, and discussion of management with an external provider — organized into categories. Simply ordering a test one also bills, or documenting a complaint, does not add an independent data category.

A 'split (or shared)' E/M visit in a facility setting is one in which:

• a.Care is transferred to another physician mid-visit
• b.Two physicians from different specialties each independently see the same patient on the same date and then split the reporting of the single shared visit between the two of them
• c.A physician and a nonphysician practitioner in the same group each personally perform part of the visit for the same patient on the same date✓
• d.The patient is shared between two different hospitals

A split/shared visit occurs when a physician and an NPP in the same group jointly furnish an E/M in a facility setting on the same date. Payer rules (e.g., who performs the substantive portion, and applicable modifiers such as -FS) determine which provider reports the service. It is a facility-setting concept.

Transitional Care Management (TCM) services are distinguished from a routine office visit in that TCM:

• a.Requires no communication with the patient after discharge
• b.Covers the management of a patient's transition from an inpatient/facility setting back to the community over a defined 30-day period, including a timely interactive contact and a face-to-face visit✓
• c.Is a single face-to-face office visit with no post-discharge interactive contact, no medication reconciliation, no care coordination, and no defined 30-day service period attached to it under any circumstances whatsoever
• d.Applies only to preventive-medicine encounters

TCM addresses the 30 days following discharge from an inpatient/observation/facility setting, requiring an interactive contact within a set number of business days, medication reconciliation, and a face-to-face visit within a specified timeframe, with the code level tied to the complexity of decision making. It is a care-transition service, not a single ordinary visit.