Chapter 15 — Exercises

How to use these. Sections A through F build the scoring skill element by element. Section G is the integration set — full encounters, scored end to end — and it is the one that matters. Do not skip to it.

For every item that asks for a level, write the reason next to the answer. A level without a reason is a guess that happened to be right, and it will not survive the next encounter.

Section A — New versus established (items 1–8)

For each, state new or established and the reason.

A.1 The patient has never been seen by anyone in the practice.

A.2 The patient saw the same physician in this office two years ago.

A.3 The patient saw the same physician in the hospital eighteen months ago. Never in the office.

A.4 The patient saw a physician in this group four years ago. Nobody since.

A.5 The patient is established with the group's cardiologist. Today they see the group's dermatologist.

A.6 The patient is established with Dr. A, a family physician. Dr. A is on vacation and the patient sees Dr. B, a family physician in the same group.

A.7 The patient saw a physician of the same specialty two years ago, at a different practice with a different tax identification number.

A.8 The physician interpreted this patient's electrocardiogram six months ago and billed for the interpretation. There has never been a face-to-face encounter. The patient is now scheduled for an office visit.

Section B — Problems addressed (items 9–18)

For each, state the problems element level and the reason.

B.9 One stable chronic illness at treatment goal.

B.10 Two stable chronic illnesses at treatment goal.

B.11 Three stable chronic illnesses at treatment goal.

B.12 One chronic illness with an A1c of 10.2, unchanged for two years, medication increased today.

B.13 One self-limited problem — a mild viral upper respiratory infection.

B.14 Two self-limited problems.

B.15 A new complaint with no definitive diagnosis established today; several possibilities remain open pending workup.

B.16 An acute illness with fever, chills, and myalgias.

B.17 The assessment reads: "Diabetes, hypertension, hyperlipidemia — all stable, refills sent." No individual status. No individual plan.

B.18 The assessment reads: "CKD stage 3a — followed by nephrology." Nothing else about the kidney disease appears anywhere in the note.

Section C — Data reviewed and analyzed (items 19–28)

Count the items, name the categories satisfied, and state the level.

C.19 A hemoglobin A1c is ordered. Nothing else.

C.20 A hemoglobin A1c and a lipid panel are ordered.

C.21 A comprehensive metabolic panel, a complete blood count, and a thyroid-stimulating hormone are ordered.

C.22 A comprehensive metabolic panel is ordered. (Count carefully.)

C.23 A comprehensive metabolic panel is ordered today. The physician also reviews the comprehensive metabolic panel drawn at the visit two weeks ago.

C.24 The physician reviews notes from an outside cardiology group and from an outside gastroenterology group, and orders a complete blood count.

C.25 The physician reviews a note from a partner in the same practice, same specialty, and orders a urinalysis.

C.26 The physician personally interprets a chest radiograph performed at an outside hospital, documents the interpretation, and does not bill for it. No tests ordered.

C.27 The physician personally interprets an electrocardiogram performed at an outside facility, documents the interpretation, and bills the professional component with modifier 26.

C.28 The physician orders a complete blood count, reviews an outside orthopedic note, and has a documented telephone conversation with the outside orthopedic surgeon about the management plan. No interprofessional consultation code is reported.

Section D — Risk (items 29–36)

State the risk level and the reason.

D.29 Rest, ice, and an elastic bandage.

D.30 The patient is advised to take an over-the-counter analgesic.

D.31 Metformin is continued with a documented decision to continue.

D.32 The medication list includes metformin. The assessment does not mention it.

D.33 A minor procedure is performed. The note documents no patient or procedure risk factors.

D.34 A minor procedure is performed. The note documents that the patient is on chronic anticoagulation and the risk was discussed.

D.35 The physician documents: "Discussed admission for observation; patient declined and will return tomorrow for recheck. Strict return precautions given."

D.36 The physician documents: "Patient reports inability to afford the prescribed medication; switched to a lower-cost alternative on the formulary and referred to the patient assistance program. This limitation shaped the treatment plan."

Section E — Time (items 37–44)

State the total countable time and, where asked, the code.

E.37 The physician spends 25 minutes face to face and 8 minutes reviewing prior records earlier the same morning. Established patient. Total? Code by time?

E.38 The nurse spends 20 minutes; the physician spends 15. Total?

E.39 The physician spends 28 minutes on the date of service and 10 more minutes documenting the following morning. Total? Code by time (established)?

E.40 The physician spends 40 minutes, of which 12 are performing a separately reported procedure. Total? Code by time (established)?

E.41 The physician spends 35 minutes, including 20 minutes of counseling. Established patient. Code by time? Would your answer change under the pre-2021 rules, and how?

E.42 New patient. 47 minutes total. Code by time?

E.43 Established patient. 29 minutes. Code by time?

E.44 Established patient. Documented MDM is moderate. Documented time is 26 minutes. What do you report, and why?

Section F — Prolonged services, split/shared, incident-to (items 45–50)

F.45 An established patient encounter has 58 minutes of documented total time. What do you report?

F.46 The same encounter, but the payer is Medicare. What changes?

F.47 An established patient encounter has 38 minutes of documented total time. May a prolonged service code be reported? Why or why not?

F.48 A nurse practitioner sees an established patient for three established chronic conditions with existing plans of care. The supervising physician is in the office suite. May this be billed incident-to?

F.49 Same facts, except the patient also mentions a new rash, which the nurse practitioner evaluates and treats. May this be billed incident-to? State the payment consequence.

F.50 A practice has configured its system to bill all nurse practitioner visits with established patients as incident-to. Identify the exposure, state its direction, and name the rule that attaches once it is discovered.

Section G — Integration: score the encounter (items 51–56)

For each, score all three MDM elements, apply the two-of-three rule, and state the code. Then state which single change would move the level.

G.51 Established patient. Assessment: type 2 diabetes at goal (metformin continued), essential hypertension at goal (lisinopril continued), hyperlipidemia (atorvastatin continued, lipid panel ordered). A1c ordered. No time documented.

G.52 Established patient. Assessment: one stable chronic illness (medication continued). No tests. Total time documented as 34 minutes.

G.53 New patient. Assessment: one undiagnosed new problem with uncertain prognosis. Three tests ordered. Prescription started. No time documented.

G.54 Established patient. Assessment: chronic heart failure with worsening symptoms; diuretic dose increased; admission discussed and declined by the patient with return precautions documented. Basic metabolic panel and brain natriuretic peptide ordered; outside cardiology note reviewed.

G.55 Established patient. Assessment: one self-limited problem. No tests. Over-the-counter treatment advised. No time documented.

G.56 Established patient. Assessment: "Chronic conditions stable, refills sent." Problem list shows four conditions. Two tests ordered. No time documented.

Section H — Where this touches the rest of the book (items 57–60)

H.57 (Chapter 14) Reading 4 in §15.10 concluded that modifier 25 would not be supportable. State why, using Chapter 14 §14.4's actual test rather than the different-diagnosis myth.

H.58 (Chapter 5) A physician asks you to "just document 40 minutes on these, we're always there anyway." Write the two-sentence response you would give, naming what the statement in the record would be.

H.59 (Chapter 4) Account 10-4471's note says "Time was not used for level selection on this encounter." Explain why that sentence appears in a medical record at all, and what it does for the coder.

H.60 (Chapter 33, forward) Reading 2 in §15.10 loses a level to a single missing sentence per problem. Draft the one-paragraph message you would send a physician about it — without asking them to document anything they did not do.