CPC practice questions, with answers.

Question 1A patient walks into a family medicine practice and is seen by Dr. Alvarez for the first time. The practice's records show that a different family medicine physician in the same group, Dr. Kim, treated this same patient two years and two months ago. How should today's visit be classified for E/M coding purposes?

1. New patient, because Dr. Alvarez has never personally examined this patient before
2. Established patient, because a same-specialty physician in the same group saw the patient within the three-year window
3. New patient, because the previous visit was with a different individual physician
4. Established patient, only if Dr. Alvarez reviews Dr. Kim's chart note before the visit

Question 2A patient last saw any physician at a dermatology practice four years and one month ago. The patient now returns to the same practice and is seen by a physician who previously treated them. How should this visit be classified?

1. Established patient, because the practice has an existing chart for this patient
2. New patient, because more than three years have passed since the last qualifying professional service
3. Established patient, because the same physician who previously treated the patient is seeing them again
4. New patient, only if the patient has changed insurance since the last visit

Question 3A coder reviewing a chart note for an established-patient office visit notices an unusually thorough physical exam with many documented body areas, but the medical decision making described is minimal: one stable, well-controlled problem, no data ordered or reviewed, and low risk. Under the current office/outpatient E/M guidelines, should the thorough exam push the visit to a higher code level?

1. Yes, because a more thorough exam always justifies a higher level regardless of MDM
2. No, because exam findings no longer count toward the code level; only MDM or total time determine it
3. Yes, but only if the exam findings are also summarized in the assessment and plan
4. No, because exam findings were never a leveling factor for office visits under any version of the guidelines

Question 4An established patient is seen for a newly diagnosed condition with an uncertain prognosis (high complexity for problems addressed). The physician orders and independently reviews two different diagnostic tests (moderate complexity for data). No prescription medication or other risk-bearing management option is chosen at this visit (minimal risk). Applying the two-of-three MDM rule, which best describes the overall MDM level?

1. The MDM level is capped at minimal, because the risk element is minimal
2. The MDM level cannot be determined without also considering exam findings
3. The MDM level is set by the two highest-supported elements, so it lands above minimal despite the low risk element
4. The MDM level must average all three elements together

Question 5A chart note for an established patient's visit lists a past medical history that includes well-controlled asthma from ten years ago, but the note documents no discussion, assessment, or management of asthma at today's visit -- the entire visit addresses a new complaint of ankle pain after a fall. For MDM purposes, should the asthma history count as a problem addressed at this encounter?

1. Yes, because any condition listed anywhere in the chart counts toward problems addressed
2. No, because the asthma was not evaluated or managed at this specific encounter, only listed in history
3. Yes, because chronic conditions always count regardless of whether they were discussed
4. No, because asthma can never count as a problem addressed under any circumstances

Question 6A patient with chronic reflux undergoes an upper endoscopy. The physician passes the scope through the mouth and documents examining the esophagus and stomach, then advancing the scope into the duodenum, which appears normal throughout. No biopsies are taken and no tissue is removed. Which of the following best describes how this procedure should be classified?

1. Colonoscopy, diagnostic, because the scope was fully advanced
2. EGD, therapeutic, because reaching the duodenum is itself considered an intervention
3. EGD, diagnostic, because the scope reached the duodenum but no intervention was performed
4. Flexible sigmoidoscopy, diagnostic, because only the upper structures were examined

Question 7A patient undergoes a colonoscopy with excellent bowel preparation. The physician advances the scope to the hepatic flexure but documents being unable to pass beyond that point due to dense adhesions from a prior abdominal surgery. No polyps are found in the segment examined. Should this procedure be reported as a complete colonoscopy?

1. Yes, because the bowel preparation was documented as excellent
2. No, because the cecum was not reached and documented, making this an incomplete colonoscopy
3. Yes, because the hepatic flexure is close enough to the cecum to count as complete
4. No, but only because adhesions are never an acceptable reason to stop a colonoscopy early

Question 8During an upper endoscopy, the physician examines the esophagus and stomach, advances into the duodenum, and identifies a gastric ulcer. Using biopsy forceps, the physician takes a tissue sample from the edge of the ulcer for pathology. The rest of the exam is otherwise unremarkable. How should this encounter be reported?

1. Report only a diagnostic EGD, because the biopsy was a minor part of an otherwise observational exam
2. Report an EGD with biopsy, because a tissue sample was obtained during the exam
3. Report both a diagnostic EGD and an EGD with biopsy for the same encounter
4. Report a colonoscopy with biopsy, since a biopsy determines the scope family

Question 9During a colonoscopy that reaches the cecum, the physician identifies a single 4 mm polyp in the ascending colon and removes it using biopsy forceps, with the operative note specifically stating no electrocautery current was applied. Which removal technique was used?

1. Cold biopsy forceps
2. Hot biopsy forceps
3. Snare technique
4. Ablation

Question 10During a single colonoscopy session, the physician documents removing a 2 mm polyp in the cecum using cold biopsy forceps, and separately removing a 12 mm pedunculated polyp in the transverse colon using a wire loop with electrocautery current applied. What is the most appropriate coding approach for these two lesions?

1. Evaluate and code each lesion's technique independently, since a cold-forceps removal and a hot-snare removal are distinct techniques
2. Report only the code for the larger polyp's removal, since it is the more clinically significant lesion
3. Report a single generic polypectomy code that covers the entire session regardless of technique
4. Report only the code for whichever lesion was documented first in the operative note