The 2022 Basic Evaluation and Management Guidelines for the Hospital Setting – Post Test

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Question 1 of 10

1. Question
1. Patients seen for initial day care in the hospital setting (consults, admissions) require specific documentation levels as it pertains to the history, exam, and medical decision making of an encounter. The following is FALSE with regards to these individuals:
- a. The medical decision making documentation of the highest admit (99223) needs the same documentation amount as the second highest level (99222)
- b. Four components of the HPI must be documented to capture any of the three initial day hospital codes, 99221-99223
- c. The history and exam key components need to be documented so that they will be of greater coding weight than medical decision making
- d. Under-documenting any of the history, exam, and medical decision making for billing of initial care hospital services 99221-99223 will cause the charge to be brought down to the lowest level documented
Question 2 of 10

2. Question
2. For the history key component for the 99221 (level 1 admit note), the HPI requirements
- a. Are the same as the level 2 (4 elements needed)
- b. Are less than the level 2
- c. Are less than the level 3
- d. Are not required on the level one admit
Question 3 of 10

3. Question
3. The Interval Detailed History
- a. Is required in the ED setting for all subsequent visits
- b. Has been stricken from use by the 2021 CMS Coding Primer Update
- c. Requires 1 element of the past, family, and social history to be compliant
- d. Can be used in follow-up hospital rounds, and is devoid of the past, family, and social history element requirements
Question 4 of 10

4. Question
4. Hospital Rounding Note:

Hospital day 4 for pneumonia. Fever 101 last pm with marked productive cough. Still on nebs q3h. CXR today shows worsening LUL infiltrate, now with effusion. Cont. Ancef, Levaquin and aggressive pulmonary toilette. O₂ sat 88% on RA, restarted NC oxygen @ 2 liters. MS normal, no n/v.

Which is TRUE:
- a. This history lacks the required past, family, and social history elements for the lowest rounding note, 99231, for an interval history
- b. This alone is adequate for an interval history that is detailed and equal to the highest rounding code, 99233
- c. This is appropriate for the observation follow-up, but not the inpatient level follow-up
- d. Noting that a patient has a sat of 88% is inadequate to show severity
Question 5 of 10

5. Question
5. Which one of the following is TRUE?
- a. There are multiple examination “bullets” available for credit without even touching the patient
- b. The 1995 E/M rules are set up with “bullet points” to allow more ease in capturing discrete elements
- c. The 1995 exam components are much more strict and harder to meet than the 1997 exam guidelines
- d. The 2021 CMS Examination Primer has become the coders “Bible” for auditing physicians
Question 6 of 10

6. Question
6. Regarding the 99222 and 99223 (Initial Inpatient Care) admission codes…
- a. One well documented organ system and another organ system addressed would meet the criteria for the exam for these encounters
- b. They have identical requirements with respect to the exam documentation, a comprehensive examination
- c. The 99223 has more exam requirements than the 99222
- d. The 99221 has the same exam requirements as the 99222 and 999223
Question 7 of 10

7. Question
7. A patient on day two of a hospital stay for pneumonia is found to have persistently elevated blood pressure since admission. You decide to start a new med to treat the newly diagnosed hypertension, but you do no further work-up. You note the pneumonia as “improving, start to wean O₂ in AM”. The medical decision making for the diagnoses managed in this encounter would be …
- a. Low (99231)
- b. Moderate (99232)
- c. High (99233)
- d. Critical (99234)
Question 8 of 10

8. Question
8. The decision to manage a prescription medication (to start, stop, or continue) is indicative of what level of MDM on the RISK table regarding subsequent hospital care?
- Straightforward/low, 99231
- Moderate, 99232
- High, 99233
- There is no RISK assessment for subsequent hospital rounding MDM
Question 9 of 10

9. Question
9. The patient with a new problem (acute abdominal pain, RLQ) is noted today on rounds. You are not sure what the etiology is of her condition, but she needs urgent evaluation and further work-up (rebound tenderness, fever, nausea). The MDM of the risk associated with this encounter where there is a new problem and further work-up is planned is
- a) Straightforward
- b) Low
- c) Moderate
- d) High, 99233 if other documentation supports
Question 10 of 10

10. Question
10. The new RLQ abdominal pain patient would need what minimum history documented to merit the 99233 subsequent rounding visit?
- a. Complete HPI and a 10-point ROS history
- b. 4 HPI elements and 2 ROS, the interval detailed history
- c. 1 HPI element and 10 ROS
- d. A tweaked copy/paste note from the day prior is sufficient

The 2022 Basic Evaluation and Management Guidelines for the Hospital Setting – Post Test

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