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 counting history bullets and examination elements
• b.By either the total time spent on the date of the encounter OR the level of medical decision making (MDM)✓
• c.By the number of organ systems reviewed in the ROS
• d.By the severity of the chief complaint alone

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.History, examination, and time
• b.Number and complexity of problems addressed; amount and/or complexity of data reviewed and analyzed; and risk of complications/morbidity of management✓
• c.Chief complaint, review of systems, and past/family/social history
• d.Coordination of care, counseling, and nature of the presenting problem

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 the E/M is the only service billed that day
• c.When a physician requests a consultation from a specialist
• d.When reporting a preventive medicine (wellness) visit

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.