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COVID-19 testing

Select the most appropriate response. Be sure to refer to both textbook content and CPT Evaluation and Management section guidelines and notes.

1) A 54-year-old patient registers at an urgent care center for COVID-19 testing due to aching, coughing, fatigue, and fever. From which Evaluation and Management category would the code for this encounter be selected?

• Preventive medicine services
• Emergency department services
• Office or other outpatient services
• Consultations

2) An established patient receives hospital inpatient discharge day management services from the provider. From which Evaluation and Management subcategory of the hospital inpatient and observation care services category would the code for this encounter be selected?
• Hospital inpatient or observation discharge services
• Hospital inpatient or observation care services (including admission and discharge services)
• Initial hospital inpatient or observation care
• Subsequent hospital inpatient or observation care

3) On January 10, a physician provided office E/M services to a 72-year-old patient who is recuperating at home after left hip replacement surgery, and that same physician created an initial home health care plan on the same date. That physician also prepared a subsequent care plan on January 22 to increase the frequency of physical therapy services provided to the patient. Reporting codes from the Care Plan Oversight Services for January 10 and January 22 care plan oversight services is appropriate because
• the same physician reported care plan oversight services during a 30-day period.
• work involved in providing care plan oversight services is not included in office visit codes.
• level of medical decision making for care plan oversight services determines code selection.
• care plan oversight services are reported instead of office or other outpatient services codes.

4) A patient was seen in consultation with a hematology specialist for post-COVID recurrent blood clots, and the specialist assumed responsibility for the patient's care after initial consultation. Subsequent office encounters with the specialist should be reported with codes from the __ category or subcategory.
• special evaluation and management services
• office or other outpatient services
• office or other outpatient consultations
• transitional care management services

5) A patient underwent emergency appendectomy as a hospital inpatient and was discharged home for recuperation. The patient then returned to the hospital, seeking immediate medical attention due to surgical staples separating at the site of incision. From which Evaluation and Management category would the code be selected?
• Prolonged services
• Emergency department services
• Care management services
• Office or other outpatient services

Full Answer Section

Correct Answer: Hospital inpatient or observation discharge services
Explanation: CPT guidelines specifically separate discharge day management services from the ongoing daily care. "Hospital inpatient or observation care services (including admission and discharge services)" would be used when the admission and discharge occur on the same day. "Initial hospital inpatient or observation care" is for the first day, and "Subsequent hospital inpatient or observation care" is for daily visits after the initial day.

Correct Answer: work involved in providing care plan oversight services is not included in office visit codes.
Explanation: CPT guidelines explicitly state that Care Plan Oversight (CPO) services are for physician supervision of patients under a home health agency or hospice, and the time spent on CPO is separate from the time reported for other E/M services (like an office visit). CPO is typically billed for a 30-day period when the physician spends a minimum of 30 minutes providing specific oversight activities not directly related to face-to-face encounters or other billable services. The other options are incorrect: CPO isn't necessarily reported by the same physician over 30 days if multiple physicians are involved, it's about the time and activities, not just the MDM level, and it's reported in addition to (not instead of) other E/M services for that patient.

Correct Answer: office or other outpatient services
Explanation: CPT guidelines are very clear on consultations. An initial consultation code is used when a provider is asked for an opinion or advice. However, once the consultant (the hematology specialist in this case) assumes responsibility for the patient's ongoing management, subsequent visits are no longer considered consultations. They revert to the standard E/M codes appropriate for the setting, which in an office setting, are "Office or other outpatient services." "Office or other outpatient consultations" would only be used for initial consultation services.

Sample Answer

Correct Answer: Office or other outpatient services
Explanation: An urgent care center, while providing immediate care, typically functions similarly to an outpatient clinic for coding purposes when the patient is seen for symptoms that don't necessarily require emergency department-level care. Preventive medicine services are for routine check-ups without current illness. Emergency department services are for true emergencies. Consultations require a specific request from another provider to offer an opinion or advice. In this case, the patient is seeking evaluation and management of current symptoms in an outpatient setting.