Posted: May 15th, 2024

A patient presents to the emergency department after having twisted his ankle while playing football

Question 1 A patient presents to the emergency department after having twisted his ankle while playing football with a group of friends. The patient complains of pain in his left ankle. The physician examines the patient’s ankle, notes swelling and tenderness, and obtains an X-ray to rule out any fracture. The nursing staff places the patient’s ankle in a soft cast before the patient leaves. This level/complexity of MDM was

Selected response: low.

Reason: The case involves an acute uncomplicated injury addressed through limited data review from one X-ray. Management includes a soft cast with low risk of complications. This aligns with low medical decision making under updated guidelines (American Medical Association, 2023).

Question 2 What is the correct code range for the subcategory of inpatient Critical Care Services for a pediatric patient?

Selected response: 99471–99476.

Reason: Codes 99471 and 99475 cover initial inpatient critical care for children aged 29 days to 5 years. Codes 99472 and 99476 apply to subsequent days. This range supports evaluation and management of critically ill pediatric patients (Centers for Medicare & Medicaid Services, 2023).

Question 3 The physician treated a new patient in the office and the following was documented: This 35-year-old single female has just recently moved to area. S: Patient needs refill on medication for hypertension. Patient also complains of “soreness” of her right elbow. No recent physical trauma. O: Limited range of motion, right elbow. Tenderness upon palpation. BP 140/80. A: Possible tennis elbow. Send for radiographs of elbow this week. Scripts given for atenolol for BP. P: Schedule appointment in one week to review X-ray results and check BP. Which part of this note is used to determine medical decision making?

Selected response: Possible tennis elbow. Send for radiographs of elbow this week.

Reason: This section shows assessment of problems and orders for tests. It reflects data analysis and risk from diagnostic steps. Guidelines base medical decision making on these elements (American College of Emergency Physicians, 2023).

Question 4 Which category/subcategory of evaluation and management would be reviewed to select an appropriate code documented as follows: This 35-year-old single female has just recently moved to area. S: Patient needs refill on medication for hypertension. Patient also complains of “soreness” of her right elbow. No recent physical trauma. O: Limited range of motion, right elbow. Tenderness upon palpation. BP 140/80. A: Possible tennis elbow. Send for radiographs of elbow this week. Scripts given for atenolol for BP. P: Schedule appointment in one week to review x-ray results and check BP.

Selected response: Office or Other Outpatient Services, New Patient.

Reason: The note describes a new patient visit for problem-oriented care. It excludes preventive or consultation services. Guidelines direct code selection from this subcategory (Infectious Diseases Society of America, 2023).

Question 5 What are the key components of an E/M service for Emergency Department Services?

Selected response: History, examination, and medical decision-making.

Reason: Providers document history to identify issues. Examination assesses physical status. Medical decision making drives the service level (American Medical Association, 2023).

Question 6 The provider saw a patient for a subsequent hospital visit. The patient is post-tonsillectomy XH 2 days. Patient is still unable to speak in a clear voice. Bleeding has increased in the surgical area. Patient will have to be taken back to the operating room for hemorrhage control. Which level of MDM is documented?

Selected response: High.

Reason: The case shows a complicated postsurgical issue with increased bleeding. Decision for return to operating room indicates high risk. This meets high medical decision making criteria (Centers for Medicare & Medicaid Services, 2023).

Question 7 The patient presents to the emergency department with the chief complaint of difficulty swallowing. All types of food are a problem. Liquids are not. The patient does not report any chest pain or pain when lying down. The patient has pain only when swallowing; the pain is a severe burning-type pain. He has been eating soft foods and soups for the past two weeks. This problem started two weeks ago and slowly has gotten worse over time. The patient is on no medications. The patient has a family history of breast and colon cancer. The patient is a former one-pack-per-week smoker. He quit smoking 10 years ago. The ROS is positive for joint pain in the right knee on and off. No medication or treatment for this. The patient did injure his knee as a child in a skiing accident, but that was 30 years ago. Remainder of ROS is negative. Which level of medical decision-making is documented?

Selected response: Moderate.

Reason: Symptoms suggest an undiagnosed problem with uncertain prognosis. Family history raises concern for serious conditions. This supports moderate complexity in decision making (American College of Emergency Physicians, 2023).

Question 8 The following was documented on the initial visit note for a new patient at a skilled nursing facility (SNF). The patient is a 55-year-old female who suffered a stroke on December 14. The patient’s daughter found her on that date, unconscious on the kitchen floor. It was not known how long the patient was there. The patient was taken to Valley Road Hospital and was admitted for treatment. Severe left-sided hemiplegia and dysphasia were present at admission to hospital. The patient also has a history of type 2 diabetes mellitus and GERD. Current orders from hospital attending are for sliding scale of insulin injections. The patient also has a feeding tube present. The left-sided hemiplegia is still present and is of a moderate nature, and the patient will require physical and speech therapy. The patient is admitted for physical and speech therapy. Her blood sugars will be closely monitored, and her tube feedings will continue. Which level of medical decision-making is documented?

Selected response: High.

Reason: Multiple acute conditions require therapy and monitoring. Insulin management and tube feedings add risk. Guidelines classify this as high decision making (Infectious Diseases Society of America, 2023).

Question 9 The following is documented on the observation note of a patient: The patient was admitted yesterday to the observation unit with the r/o diagnosis of severe back pain. The patient was in an automobile accident prior to admission to the unit. Physical exam at the time was negative for any fractures. Radiology reports were also negative for any fractures. However, due to the patient’s severe discomfort, he was admitted for observation. Examination on day 2 in the unit shows a 45-year-old man in moderate distress despite prescription analgesics. MS: Pain over the lower lumbar region, ROM is limited especially on the left side. No visible swelling but tenderness on palpation. Muscle strength and tone normal on right. Decreased on left. Gait abnormal with leaning at midsection. Plan: Reexamine radiograph reports and films. Possible MRI of lumbar spine to rule out herniation of disc. Which level of medical decision-making is documented?

Selected response: Moderate.

Reason: Persistent pain after accident prompts data review and potential MRI. This involves moderate data and risk. Updated guidelines support this level (American Medical Association, 2023).

Question 10 The following information was documented on a patient seen in the physician’s office. Review of lab tests and uroflowmetry suggests benign prostatic hypertrophy. The patient’s urine flow was 8 mm. PSA test was slightly elevated. Repeated PSA today. TURP was discussed with patient. Risks and benefits of procedure discussed in detail. Patient has agreed to surgery. Surgery will be scheduled for next week. Which level of medical decision-making is documented?

Selected response: High.

Reason: Elevated PSA requires repeat testing and data analysis. Decision for surgery involves high risk discussion. This qualifies as high under guidelines (Centers for Medicare & Medicaid Services, 2023).

References American Medical Association (2023) CPT E/M descriptors and guidelines. Available at: https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf (Accessed: 15 August 2025).

American College of Emergency Physicians (2023) 2023 Emergency Department Evaluation and Management Guidelines. Available at: https://www.acep.org/administration/reimbursement/reimbursement-faqs/2023-ed-em-guidelines-faqs (Accessed: 15 August 2025).

Centers for Medicare & Medicaid Services (2023) Evaluation and Management Services. MLN006764. Available at: https://www.cms.gov/files/document/mln006764-evaluation-management-services.pdf (Accessed: 15 August 2025).

Infectious Diseases Society of America (2023) Evaluation and Management Services Reference Guide. Available at: https://www.idsociety.org/globalassets/idsa/clinical-affairs/2023-em-services-reference-guide-final.pdf (Accessed: 15 August 2025).

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