Wiki E/M Consultation - CPC exam prep question - help

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carrie.townsend@modahealth.com

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I am sitting for my CPC exam on Saturday. There is a question in the Study Guide that has me stumped (and my two CPC colleagues too).

A 55-year-old patient is seen in an office visit by an otolaryngologist. Dr. Nettles, at the request of her primary care provider for sudden hearing loss. The patient experience sudden vertigo ten days ago accompanied by hearing loss in the right ear. The patient has no history of vertigo or ear infections. An MRI of the brain is ordered.

Dr. Nettles suspects her vertigo may be due to a virus of the 8th cranial nerve and with time, her hearing may return. Quarterly hearing tests are recommended to monitor hearing in the left ear. If there is little or no improvement, a bone anchored hearing aid is an option. A report is sent to the primary care provider.

A comprehensive history, expanded problem focused exam and moderate medical decision making was documented.

What E/M service is reported?

  1. 99204
  2. 99252
  3. 99244
  4. 99242
*****
My thoughts: This meets the requirements of a consultation E/M:
  1. Request
  2. Report
  3. Response
This would lead me to the 99241-99245 codes. This eliminates A and B

Normally I would select D. The guidelines say that these E/M codes need to meet 3 key components. Answers C and D don’t meet ALL three components. Answer C meets two of the requirements and D only meets 1. I would have answered C since it meets more of the requirements but the correct answer is D. ????? I don’t understand why.

The rational says:
This documentation meets the three requirements of Request, Render and Reply. This eliminates answer choice A. The consultation is performed in an office, eliminating Answer choice B. Theses E/M services require 3 key components which meet or exceed the level of service. A comprehensive history, expanded problem focused exam and moderate MDM is coded with 99242.

Can anyone explain this to me? Your help is GREATLY appreciated.
 
carrie.townsend@modahealth.com said:
I am sitting for my CPC exam on Saturday. There is a question in the Study Guide that has me stumped (and my two CPC colleagues too).

A 55-year-old patient is seen in an office visit by an otolaryngologist. Dr. Nettles, at the request of her primary care provider for sudden hearing loss. The patient experience sudden vertigo ten days ago accompanied by hearing loss in the right ear. The patient has no history of vertigo or ear infections. An MRI of the brain is ordered.

Dr. Nettles suspects her vertigo may be due to a virus of the 8th cranial nerve and with time, her hearing may return. Quarterly hearing tests are recommended to monitor hearing in the left ear. If there is little or no improvement, a bone anchored hearing aid is an option. A report is sent to the primary care provider.

A comprehensive history, expanded problem focused exam and moderate medical decision making was documented.

What E/M service is reported?

  1. 99204
  2. 99252
  3. 99244
  4. 99242
*****
My thoughts: This meets the requirements of a consultation E/M:
  1. Request
  2. Report
  3. Response
This would lead me to the 99241-99245 codes. This eliminates A and B

Normally I would select D. The guidelines say that these E/M codes need to meet 3 key components. Answers C and D don’t meet ALL three components. Answer C meets two of the requirements and D only meets 1. I would have answered C since it meets more of the requirements but the correct answer is D. ????? I don’t understand why.

The rational says:
This documentation meets the three requirements of Request, Render and Reply. This eliminates answer choice A. The consultation is performed in an office, eliminating Answer choice B. Theses E/M services require 3 key components which meet or exceed the level of service. A comprehensive history, expanded problem focused exam and moderate MDM is coded with 99242.

Can anyone explain this to me? Your help is GREATLY appreciated.
Click to expand...

All 3 components have to be met or exceeded. For 99244, only 2 of the 3 are met, so it can't be the correct code.

The expanded problem-focused examination makes it a 99242.
 
The level is limited by the EPF exam. Since the higher level office consultation codes require at least a detailed exam, the documentation doesn't support any of those.
 
Hi. Let me restate the answers to the question with letters, to minimize confusion:

A. 99204
B. 99252
C. 99244
D. 99242

We can eliminate A because, as you said it is a consultation service that meets the 3 R's.
We can eliminate B because it is an office consultation, and 99252 is an inpatient consultation.

For the remaining choices, we can't select C because we have not reached the threshold of a comprehensive history, comprehensive physical exam, and moderate medical decision making. We need to have all 3 of these key components to report CPT 99244. We have the history, and the medical decision making, but not the physical exam. We have to drop the level down until we get to the level where we "meet" the component. And that takes you down to 99242, which has the EPF physical exam.
 
AaPe12 said:
Hi. Let me restate the answers to the question with letters, to minimize confusion:

A. 99204
B. 99252
C. 99244
D. 99242

We can eliminate A because, as you said it is a consultation service that meets the 3 R's.
We can eliminate B because it is an office consultation, and 99252 is an inpatient consultation.

For the remaining choices, we can't select C because we have not reached the threshold of a comprehensive history, comprehensive physical exam, and moderate medical decision making. We need to have all 3 of these key components to report CPT 99244. We have the history, and the medical decision making, but not the physical exam. We have to drop the level down until we get to the level where we "meet" the component. And that takes you down to 99242, which has the EPF physical exam.
Click to expand...
In this instance, the CPC book says "...which required these 3 key components" for selecting the E/M. So if all three are not met at one level, then you drop down to the next level? All three aren't met at 99244, so the next level is 99242 by default?
 
You have to meet or exceed each of the 3 key components for consultation codes. Side note - same applies to initial inpatient visits 99221-99223.
So basically, your code is whatever the lowest level is for each of history, exam & MDM. In your example, the expanded problem focused exam (level 2) means regardless of history or MDM, the highest it could be is 99242.
Examples:
History levelExam levelMDM levelConsult level
43399243
52599242
24499242
55399243
 
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