22 Evaluation & Management (E/M) Practice Questions & Answers

1. 1. An office note for an established patient documents a thorough history, a detailed physical exam, the physician's medical decision making, and the total time spent on the date of the encounter. Under the current CPT E/M framework, how does the coder determine the level of service?

   • A.By total time only, because time is documented in the note
   • B.By either the level of MDM or the total time on the date of the encounter, whichever the documentation supports; history and exam do not drive the level✓ Answer
   • C.By the three key components of history, exam, and MDM, with two of the three required
   • D.By the extent of the history and exam, using MDM only when those two conflict

   The CPT E/M guidelines give exactly two selection pathways for the categories that have levels: the level of MDM, or the total time on the date of the encounter. The coder applies whichever pathway the provider's documentation supports. The former three-key-component method, in which the extent of history and exam helped set the level, no longer applies.

   Source: AMA CPT Professional Edition — E/M Services Guidelines, "Levels of E/M Services" (selection by MDM or by total time)Report a problem with this question

2. 2. Under the revised E/M framework, what role do the history and physical examination now play in an office or other outpatient visit?

   • A.They must be comprehensive whenever a high-level code is reported
   • B.They function as a fourth element of medical decision making
   • C.They are performed and documented as medically appropriate, but their extent does not determine the level of service✓ Answer
   • D.They may be omitted entirely, since they no longer affect the code

   CPT states that a medically appropriate history and/or examination is performed when indicated by the clinical situation, and the treating provider decides its nature and extent. Because it is a clinical judgment rather than a scoring element, no amount of history or exam can raise or lower the level; only MDM or total time can.

   Source: AMA CPT Professional Edition — E/M Services Guidelines, "History and/or Examination"Report a problem with this question

3. 3. A visit is documented with two stable chronic illnesses (moderate for problems), review of two prior external notes from two different sources (limited data), and prescription drug management (moderate risk). What is the level of MDM and why?

   • A.Straightforward, because only one element clearly reaches moderate
   • B.Low, because all three elements must reach moderate before that level can be used
   • C.High, because the number of chronic problems plus a prescription always escalates the level
   • D.Moderate, because two of the three MDM elements are met or exceeded at that level✓ Answer

   CPT requires that two of the three MDM elements be met or exceeded at a given level. Here the problems element and the risk element both reach moderate, so the data element being only limited does not pull the level down.

   Source: AMA CPT Professional Edition — E/M Services Guidelines, Table 1 (Levels of Medical Decision Making) — two of three elements must be met or exceededReport a problem with this question

4. 4. At an office visit the physician treats acute sinusitis, writes in the assessment that the patient's atrial fibrillation is 'followed by cardiology, no change,' and sends the patient to dermatology for a skin lesion without evaluating it. For the problems element of MDM, which problems were addressed?

   • A.The sinusitis and the skin lesion, because a referral is a form of management
   • B.The sinusitis and the atrial fibrillation, because a documented chronic condition always counts
   • C.Only the sinusitis, because the other two were merely noted or referred without evaluation or consideration of treatment✓ Answer
   • D.All three, because each condition appears in the assessment

   CPT defines a problem addressed as one that is evaluated or treated at the encounter by the reporting provider. Noting that another professional is managing a condition, or referring a problem out without evaluating it or considering treatment, does not qualify — otherwise a problem list alone could inflate the level.

   Source: AMA CPT Professional Edition — E/M Services Guidelines, definition of "Problem addressed"Report a problem with this question

5. 5. A patient with hypertension of several years' duration returns. Blood pressure has been essentially unchanged for a year and the patient is asymptomatic, but every reading remains well above the goal the physician documented for this patient, and therapy is adjusted. For MDM, how is this chronic illness classified?

   • A.A chronic illness that is not stable, because 'stable' is defined by the patient's documented treatment goal, not by the absence of change✓ Answer
   • B.An acute uncomplicated illness, because the medication was changed today
   • C.A stable chronic illness, because the patient reports no symptoms
   • D.A stable chronic illness, because the readings have not changed over the past year

   CPT ties 'stable' to the specific treatment goal set for that patient. A patient who is not at goal is not stable even if the condition is unchanged and asymptomatic, which is why persistently poorly controlled hypertension scores higher than a stable chronic illness.

   Source: AMA CPT Professional Edition — E/M Services Guidelines, definition of "Stable, chronic illness"Report a problem with this question

6. 6. A physician orders a basic metabolic panel and a complete blood count with differential (the note separately lists the hemoglobin and platelet count from that CBC), and the medical assistant records three pulse oximetry readings during the visit. For Category 1 of the data element, how many unique tests are counted?

   • A.One
   • B.Three
   • C.Two✓ Answer
   • D.Five

   A clinical laboratory panel is a single test no matter how many analytes it contains, and tests with overlapping elements are not unique — the hemoglobin and platelet count are subsumed by the CBC with differential. Pulse oximetry is expressly not counted as a test for the data element, so only the panel and the CBC count.

   Source: AMA CPT Professional Edition — E/M Services Guidelines, "Amount and/or Complexity of Data to Be Reviewed and Analyzed" (unique test; panels; tests not counted)Report a problem with this question

7. 7. During an office visit the physician personally interprets an ECG and reports the professional component of that interpretation as a separate service. May the same interpretation also be counted toward the data element of MDM?

   • A.No, because a service for which the provider separately reports the interpretation cannot also be counted as data for the same encounter✓ Answer
   • B.Yes, provided the interpretation is documented in a separate paragraph of the note
   • C.Yes, but only toward Category 1 as a unique test ordered
   • D.Yes, because the physician personally performed the interpretation

   CPT bars double counting: the independent-interpretation category applies only when the interpretation is not separately reported, and any work billed as its own service is excluded from the data element. Otherwise the same physician effort would be paid once as a procedure and again as a driver of the E/M level.

   Source: AMA CPT Professional Edition — E/M Services Guidelines, "Amount and/or Complexity of Data" (independent interpretation not separately reported)Report a problem with this question

8. 8. Which situation qualifies as use of an independent historian for the data element of MDM?

   • A.A spouse sits in on the visit while the patient recounts the full history himself
   • B.The mother of a toddler with a seizure provides the history because the child cannot give a complete or reliable one✓ Answer
   • C.A medical interpreter translates for a patient who gives a complete and reliable history in her own language
   • D.A nurse relays the patient's own account to the physician after rooming the patient

   An independent historian is an individual who provides history because the patient is unable to give a complete or reliable one, or because a confirmatory history is judged necessary. Translation services do not count, and a companion who adds nothing the patient could not supply is not an independent historian.

   Source: AMA CPT Professional Edition — E/M Services Guidelines, definition of "Independent historian(s)"Report a problem with this question

9. 9. A coder wants to credit Category 3 of the data element, discussion of management or test interpretation with an external physician or other appropriate source. Which documentation supports it?

   • A.The physician read the consultant's written report in the chart and agreed with the plan
   • B.The physician and an external specialist spoke directly about the treatment plan, and the exchange was initiated and completed within a day✓ Answer
   • C.The office staff left a message for the consultant summarizing the physician's questions
   • D.The physician discussed the plan with the patient's adult daughter, who is the informal caregiver

   CPT requires a direct interactive exchange between the reporting provider and the external professional; sending or reading messages through clinical staff or the chart is not a discussion. Family members and informal caregivers are not an 'appropriate source,' and the exchange must be initiated and completed within a short time.

   Source: AMA CPT Professional Edition — E/M Services Guidelines, "Amount and/or Complexity of Data" (Category 3: discussion of management or test interpretation)Report a problem with this question

10. 10. An established patient is seen for a single acute uncomplicated illness. No tests are ordered or reviewed and no outside records exist. The physician prescribes an antibiotic. Which statement correctly describes the MDM?

    • A.The MDM is high, because any prescription implies systemic treatment
    • B.The MDM cannot be scored because no data element is present
    • C.The MDM is moderate, because prescription drug management is a moderate-risk example
    • D.The MDM is low, because only the risk element reaches moderate and two of three elements are required✓ Answer

    Prescription drug management is only an example under the risk element, and risk is one of three elements. With problems at low (one acute uncomplicated illness) and data minimal, only one element reaches moderate, so the two-of-three rule caps the MDM at low.

    Source: AMA CPT Professional Edition — E/M Services Guidelines, Table 1 (Risk element; two of three elements must be met or exceeded)Report a problem with this question

11. 11. After shared decision making, a physician documents that hospitalization was seriously considered for a patient with worsening heart failure but was declined in favor of intensified outpatient therapy with next-day follow-up. How does this affect the risk element?

    • A.The documented consideration of hospitalization counts toward risk, because risk includes management options considered but not selected✓ Answer
    • B.It does not count, because the patient was not actually admitted
    • C.It converts the encounter into a hospital service regardless of where it took place
    • D.It does not count, because risk is measured only by the severity of the underlying condition

    The risk element measures the risk of patient management, not of the disease itself, and CPT expressly includes options that were considered but not selected after shared decision making. The documented decision about hospitalization therefore counts even though the patient went home.

    Source: AMA CPT Professional Edition — E/M Services Guidelines, "Risk of Complications and/or Morbidity or Mortality of Patient Management"Report a problem with this question

12. 12. When the risk element turns on whether a planned operation is 'minor' or 'major' surgery, how is that distinction made?

    • A.By whether general anesthesia is planned
    • B.By common clinical usage, that is, how the procedure is ordinarily regarded in practice✓ Answer
    • C.By whether the procedure is performed in an operating room
    • D.By the global period assigned to the procedure in the surgical package classification

    CPT states that minor and major surgery in the risk table follow common clinical usage and are deliberately not tied to the surgical-package or global-period classification. Elective versus emergency is likewise a description of timing, and the presence of patient- or procedure-specific risk factors is what separates moderate from high risk.

    Source: AMA CPT Professional Edition — E/M Services Guidelines, definitions of "Surgery — minor or major" and "Surgery — elective or emergency"Report a problem with this question

13. 13. A physician selects the level of an office visit using total time. Which of these may be included in total time on the date of the encounter?

    • A.Time the nurse spent taking vital signs and giving discharge instructions
    • B.Time the physician spent teaching a resident about pharmacology in general
    • C.Time the physician spent driving between two clinic sites that day
    • D.Time the physician spent that morning reviewing the patient's prior results in preparation for the visit✓ Answer

    Total time is all time personally spent by the physician or other qualified health care professional on the date of the encounter, face-to-face and non-face-to-face, and CPT expressly lists preparing to see the patient, such as reviewing tests, as countable. Clinical staff time, travel, and teaching not specific to this patient's management are excluded.

    Source: AMA CPT Professional Edition — E/M Services Guidelines, "Time" (activities that count toward total time on the date of the encounter)Report a problem with this question

14. 14. On the date of an office visit selected by total time, the physician also performs and separately reports a minor procedure. How is the procedure time handled?

    • A.It is added to total time because it occurred on the same date
    • B.It is excluded, because time spent on a separately reported service may not also count toward the E/M total time✓ Answer
    • C.It is added at half value, since the work overlaps the visit
    • D.It is added only if the procedure was performed before the E/M discussion

    CPT excludes from total time the performance of other services that are reported separately, for the same reason it excludes separately reported interpretations from the data element: the same minutes cannot be paid twice, once as the procedure and once as a driver of the E/M level.

    Source: AMA CPT Professional Edition — E/M Services Guidelines, "Time" (activities that do not count toward total time)Report a problem with this question

15. 15. A physician begins an evaluation at 11:40 pm and the work continues without interruption until 12:20 am the next calendar day. Under the CPT time rules, how is this reported?

    • A.As one service on the later date, with the earlier minutes discarded
    • B.As two separate E/M services, one on each calendar date
    • C.As one service, but only the minutes before midnight may be counted
    • D.As a single service reported on one date, because a continuous service that spans midnight is not split✓ Answer

    Total time is counted by calendar date, but CPT makes an explicit allowance for a service that is continuous and passes midnight: it is a single service reported on one date rather than two partial services, so all of the continuous minutes support one code.

    Source: AMA CPT Professional Edition — E/M Services Guidelines, "Time" (total time on the date of the encounter; continuous service spanning midnight)Report a problem with this question

16. 16. Almost the entire visit is spent counseling a patient and her husband about treatment options for a newly diagnosed condition. Under the current framework, how should the level be supported?

    • A.By documenting a comprehensive history to justify the added work
    • B.By documenting that counseling exceeded 50% of the face-to-face time
    • C.By documenting total time on the date of the encounter, since counseling is a countable activity and no percentage rule applies✓ Answer
    • D.By defaulting to the lowest level, because counseling generates no data or risk

    Counseling and educating the patient, family, or caregiver is on the CPT list of activities that count toward total time, and the old requirement that counseling dominate more than half of the face-to-face time was eliminated with the revised framework. The provider simply reports the level supported by total time, or by MDM if that is higher.

    Source: AMA CPT Professional Edition — E/M Services Guidelines, "Time" (counseling and educating as a countable activity; no counseling-dominance requirement)Report a problem with this question

17. 17. A patient saw a cardiologist in a multispecialty group two years ago. She now presents to a gastroenterologist in that same group who has never seen her. Is she a new or established patient to the gastroenterologist?

    • A.New, because more than one year has passed since the prior visit
    • B.Established, because any face-to-face service within the same group within three years makes her established
    • C.Established, because she has an active record at that practice
    • D.New, because the prior service was by a physician of a different specialty, even though it was in the same group and within three years✓ Answer

    A patient is established only if she received a face-to-face professional service within the past three years from that same physician or from another physician of the exact same specialty and subspecialty in the same group. Cardiology and gastroenterology are different specialties, so the three-year clock is not triggered here.

    Source: AMA CPT Professional Edition — E/M Services Guidelines, "New and Established Patient"Report a problem with this question

18. 18. Dr. Lee is on call covering for Dr. Ramirez and sees one of Dr. Ramirez's regular patients in the office. How is the new-versus-established determination made for Dr. Lee's service?

    • A.The patient is new until Dr. Lee has personally seen her twice
    • B.The covering physician is classified the same way the physician he is covering for would have been classified✓ Answer
    • C.The determination depends on whether Dr. Lee has access to the patient's chart
    • D.Dr. Lee always reports a new patient service because he has never seen the patient

    CPT provides that a physician who is on call for or covering for another physician is classified exactly as the physician who is unavailable would be. Because the patient is established to Dr. Ramirez, the covering visit is reported as an established patient service.

    Source: AMA CPT Professional Edition — E/M Services Guidelines, "New and Established Patient" (on-call and covering physicians)Report a problem with this question

19. 19. A physician and a nurse practitioner in the same group both perform work during one patient encounter and jointly spend 12 minutes at the bedside discussing the plan with the patient. When the split or shared visit is leveled by time under CPT, how is that joint period counted?

    • A.Twice, but only if each documents the discussion separately
    • B.Not at all, because time spent together cannot be attributed to either practitioner
    • C.Twice, once for each practitioner, because both performed the work
    • D.Once, because only distinct time is summed and time spent jointly is counted a single time✓ Answer

    In a split or shared visit CPT sums only distinct time; when the two practitioners meet with or discuss the patient together, that period is counted once rather than doubled. The substantive-portion concept then determines which practitioner reports the service, and payer definitions of that portion may differ from CPT's wording.

    Source: AMA CPT Professional Edition — E/M Services Guidelines, "Split or Shared Visits"Report a problem with this question

20. 20. A surgeon receives a written request from a family physician asking for an opinion on whether a patient's abdominal pain requires operative treatment. The surgeon evaluates the patient and sends a written report back with recommendations. Later, the family physician instead sends a patient directly to the surgeon to assume all management of a hernia. Which statement is correct?

    • A.Both are transfers of care, because the surgeon saw the patients in person
    • B.The first is a consultation because it was requested, rendered, and reported back; the second is a transfer of care reported with the ordinary new or established patient visit codes✓ Answer
    • C.Both encounters are consultations, because both originated with another physician
    • D.Neither is a consultation, because the surgeon may ultimately operate

    Where consultation codes are recognized, CPT requires a request from another physician, qualified health care professional, or appropriate source, an opinion rendered on a specific problem, and a written report communicated back to the requester. When the referring physician instead hands over management of the problem, that is a transfer of care and is reported with the ordinary visit codes.

    Source: AMA CPT Professional Edition — E/M Services Guidelines, "Consultation" (request, render, written report; transfer of care)Report a problem with this question

21. 21. Which statement correctly describes when prolonged services time may be added to an office or other outpatient E/M service?

    • A.Whenever the visit runs longer than scheduled, regardless of how the base level was selected
    • B.Whenever the MDM is high and the physician documents extra effort
    • C.Only when the base service was selected using time rather than MDM, only with the highest level in that family, and only after a full additional increment of time has elapsed✓ Answer
    • D.Only when the extra time occurs on a date after the face-to-face encounter

    Prolonged service add-on codes measure time beyond the primary service, so they are meaningful only when the primary service itself was leveled by time, and they attach to the highest-level code in the family because there is no higher base code left to absorb the minutes. No unit is reported until a complete additional increment is reached.

    Source: AMA CPT Professional Edition — Prolonged Services guidelines (prolonged service on the date of an office or other outpatient E/M service)Report a problem with this question

22. 22. An emergency department note documents extensive physician time as well as the medical decision making for the encounter. How is the ED service leveled?

    • A.By MDM only, because time is not a descriptive component of emergency department services✓ Answer
    • B.By whichever of time or MDM yields the higher level, as in the office setting
    • C.By time only, because emergency care is inherently time intensive
    • D.By time, but only when the patient is later admitted

    Emergency department services are leveled by medical decision making alone; CPT excludes time as a descriptive component because ED work is provided in variable intensity, often to several patients at once, so a time pathway would not reflect the service. Documented minutes therefore cannot raise the ED level.

    Source: AMA CPT Professional Edition — Emergency Department Services guidelines (level selection by MDM; time not a descriptive component)Report a problem with this question

Practice questions based on the ICD-10-CM Official Guidelines for Coding and Reporting, the AMA CPT guidelines, the CMS HCPCS Level II system, and federal healthcare compliance law. CPC is a mark of the AAPC and CPT is a mark of the American Medical Association; this site is not affiliated with or endorsed by either. ICD-10-CM, CPT, and HCPCS Level II are revised every year, so these questions test coding rules and conventions rather than code values — always verify actual code selection against the current code books and your payer's published policy. Nothing here is medical, legal, or billing advice. About the CPC exam →