AAPC Chapter 19 Exam
with verified answers and rationales
1. NEW PATIENT OFFICE VISIT
CHIEF COMPLAINT: Right inguinal hernia.
HISTORY OF PRESENT ILLNESS: This 44-year-old athletic man has been aware of a bulge and
a pain in his right groin for over a year. He is very active, both aerobically and anaerobically.
He has a weight routine which he has modified because of this bulge in his right groin.
Usually, he can complete his entire workout. He can swim and work without problems. Several
weeks ago, in the shower, he noticed there was a bulge in the groin and he was able to push
on it and make it go away. He has never had a groin operation on either side. The pain is
minimal, but it is uncomfortable and it limits his ability to participate in his physical activity
routine. In addition, he likes to do a lot of exercise in the back country and his personal
physician, Dr. X, told him that it would be dangerous to have this become incarcerated in the
back country. PAST MEDICAL HISTORY: Serious illnesses: Reactive airway disease for which
he takes Advair. He is not on steroids and has no other pulmonary complaints. Operations:
None.
REVIEW OF SYSTEMS: He has no weight gain or weight loss. He has excellent exercise
tolerance. He denies headaches, back pain, abdominal discomfort, or constipation.
PHYSICAL EXAMINATION: VITAL SIGNS: Weight 82 kg, temperature 36.8, pulse 48 and regular,
blood pressure 121/69.
GENERAL APPEARANCE: He is a very muscular well-built man in no distress. SKIN: Normal.
HEAD AND NECK: Sclerae are clear. External ocular eye movements are full.
Trachea is midline. Thyroid is not felt.
CHEST: Clear.
HEART: Regular.
ABDOMEN: Soft. Liver and spleen not felt. He has no abnormality in the left groin. In the right
groin I can feel a silk purse sign, but I could not feel an actual mass. I am quite sure by history
and by physical examination that he has a rather small indirect inguinal hernia. His cord and
testicles are normal.
NEURO: Grossly intact to motor and sensory examination. IMPRESSION:
Right indirect inguinal hernia.
,PLAN: We discussed observation and repair. He is motivated toward repair and I described the
operation in detail. I gave him the scheduling number and he will call and arrange the
operation. What E/M code is reported?
ANS: 99203
Rationale: New Patient
Number and Complexity of Problems - One acute uncomplicated illness or injury -
Low
Amount and/or Complexity of Data to be Reviewed and Analyzed - None
Medical decision making - elective major surgery, no identified risk factors – Moderate
2. John, a 16-year-old male, is admitted by the emergency department physician for
observation after an ATV accident. The patient is discharge from observation by another
provider the next day. What category or subcategory of evaluation and management codes
would be selected for the emergency department physician?
ANS: Initial observation care
Rationale: The patient presented to the Emergency Department and was admitted to observation by
the ED physician. The guidelines for Initial Observation Care state that all services provided by the
admitting physician for the same date of service are included in the initial hospital care, and in this
instance the emergency department services would not be coded. If the patient was discharged on
the same date of service, a code from Observation or Inpatient Care Services (Including Admission
and Discharge Services) would be selected.
3. During a soccer game, Ashley, a 26-year-old female, heard a popping sound in her knee.
Her knee has been unstable since the incident and she decided to consult an orthopedist. She
visits Dr. Howard, an orthopedist she has not seen before, to evaluate her knee pain. Dr.
Howard's diagnosis is a torn ACL. From what category or subcategory of evaluation and
management code would be selected for the visit to Dr. Howard?
ANS: Office visit, new patient
,Rationale: Consultations performed at the request of a patient are coded using office visit codes.
Because the patient has not seen Dr. Howard before, this would be considered a new patient visit.
4. The patient is seen in the nursing home today for a follow up of his hospitalization for
pneumonia. He was placed back on Singulair® and has been improving with his breathing
since then. What is the level of history?
ANS: Problem focused
5. Emergency Department
A 47-year-old white male presents to the emergency department after the four-wheeler he was
operating struck a ditch and rapidly came to a halt. This threw him against the windshield
where he struck the mid part of his face and lower lip. This resulted in lip and chin lacerations.
He is evaluated by Dr. Jones and a CT scan suggests a hyper dense abnormality within the
brain. A bleed could not be ruled out and an inpatient hospital admission is recommended.
His past history includes previous tonsillectomy, previous hospital admission for a syncopal
episode associated with pain in the groin area, and hypercholesterolemia. He has no known
allergies. His current medications are Zocor® and Accutane®. He is a non-smoker and a
moderate drinker of alcohol. The review of systems is negative for nausea, vomiting, blurred
vision, or headache. What is the level of history?
ANS: Expanded problem focused
6. Physical Exam:
GENERAL APPEARANCE: Healthy appearing individual in no distress
ABDOMEN: Soft, non-tender, without masses. No CVA tenderness FEMALE EXAM:
VULVA/LABIA MAJORA: No erythema, ulcerations, swelling, or lesions seen. BARTHOLIN
GLANDS: No cysts, abscesses, induration, discharge, masses, or inflammation noted.
SKENE'S: No cysts, abscesses, induration, discharge, masses, or inflammation noted.
CLITORIS/LABIA MINORA: Clitoris normal. No atrophy, adhesions, erythema, or vesicles
noted. Labia unremarkable.
URETHRAL MEATUS: Meatus appears normal in size and location. No masses, lesions or
prolapse.
URETHRA: No masses, tenderness or scarring.
BLADDER: Without fullness, masses or tenderness.
, VAGINA: Mucosa clear without lesions, Pelvic support normal. No discharge. CERVIX: The
cervix is clear, firm and closed. No visible lesions. No abnormal discharge.
UTERUS: Uterus non-tender and of normal size, shape and consistency. Position and mobility
are normal.
ADNEXA/PARAMETRIA: No masses or tenderness noted.
Based on the 1995 documentation guidelines, what is the level of exam?
ANS: Comprehensive
Rationale: Organ Systems: The documentation supports a comprehensive/complete single system
(Female Genitourinary) exam. The level of exam is Comprehensive.
7. Physical Exam:
CONSTITUTIONAL: Vital Signs: Pulse: 161. Resp: 30. Temp: 102.4. Oxygen saturation 90%
GENERAL APPEARANCE: The patient reveals profound mental retardation. Tracheostomy is
in place. EYES: Conjunctivae are slightly anemic. ENT: Oral mucosa is dry. NECK: The neck is
supple and the trachea is midline.
Range of motion is normal. There are no masses, crepitus or tenderness of the neck. The
thyroid gland has no appreciable goiter. RESPIRATORY: The lungs reveal transmitted upper
airway signs and bilateral rales, wheezes and rhonchi. CARDIOVASCULAR: The chest wall is
normal in appearance. Regular rate and rhythm. No murmurs, rubs or gallops are noted. There
is no significant edema to the lower extremities. GASTROINTESTINAL: The abdomen is soft
and nondistended. There is no tenderness, rebound or guarding noted. There are no masses.
No organomegaly is appreciated. SKIN: The skin is pale and slightly diaphoretic.
NEUROLOGIC: Cranial nerves appear intact. The patient moves all 4 extremities
symmetrically. No lateralizing signs are noted. Gross sensation is intact to all extremities.
LYMPHATIC: There are no palpable pathologic lymph nodes in the neck or axilla.
MUSCULOSKELETAL: Gait and station are normal. Strength and tone to the upper and lower
extremities are normal for age with no evidence of atrophy. There is no cyanosis, clubbing or
edema to the digits.
What is the level of exam?
ANS: Comprehensive
with verified answers and rationales
1. NEW PATIENT OFFICE VISIT
CHIEF COMPLAINT: Right inguinal hernia.
HISTORY OF PRESENT ILLNESS: This 44-year-old athletic man has been aware of a bulge and
a pain in his right groin for over a year. He is very active, both aerobically and anaerobically.
He has a weight routine which he has modified because of this bulge in his right groin.
Usually, he can complete his entire workout. He can swim and work without problems. Several
weeks ago, in the shower, he noticed there was a bulge in the groin and he was able to push
on it and make it go away. He has never had a groin operation on either side. The pain is
minimal, but it is uncomfortable and it limits his ability to participate in his physical activity
routine. In addition, he likes to do a lot of exercise in the back country and his personal
physician, Dr. X, told him that it would be dangerous to have this become incarcerated in the
back country. PAST MEDICAL HISTORY: Serious illnesses: Reactive airway disease for which
he takes Advair. He is not on steroids and has no other pulmonary complaints. Operations:
None.
REVIEW OF SYSTEMS: He has no weight gain or weight loss. He has excellent exercise
tolerance. He denies headaches, back pain, abdominal discomfort, or constipation.
PHYSICAL EXAMINATION: VITAL SIGNS: Weight 82 kg, temperature 36.8, pulse 48 and regular,
blood pressure 121/69.
GENERAL APPEARANCE: He is a very muscular well-built man in no distress. SKIN: Normal.
HEAD AND NECK: Sclerae are clear. External ocular eye movements are full.
Trachea is midline. Thyroid is not felt.
CHEST: Clear.
HEART: Regular.
ABDOMEN: Soft. Liver and spleen not felt. He has no abnormality in the left groin. In the right
groin I can feel a silk purse sign, but I could not feel an actual mass. I am quite sure by history
and by physical examination that he has a rather small indirect inguinal hernia. His cord and
testicles are normal.
NEURO: Grossly intact to motor and sensory examination. IMPRESSION:
Right indirect inguinal hernia.
,PLAN: We discussed observation and repair. He is motivated toward repair and I described the
operation in detail. I gave him the scheduling number and he will call and arrange the
operation. What E/M code is reported?
ANS: 99203
Rationale: New Patient
Number and Complexity of Problems - One acute uncomplicated illness or injury -
Low
Amount and/or Complexity of Data to be Reviewed and Analyzed - None
Medical decision making - elective major surgery, no identified risk factors – Moderate
2. John, a 16-year-old male, is admitted by the emergency department physician for
observation after an ATV accident. The patient is discharge from observation by another
provider the next day. What category or subcategory of evaluation and management codes
would be selected for the emergency department physician?
ANS: Initial observation care
Rationale: The patient presented to the Emergency Department and was admitted to observation by
the ED physician. The guidelines for Initial Observation Care state that all services provided by the
admitting physician for the same date of service are included in the initial hospital care, and in this
instance the emergency department services would not be coded. If the patient was discharged on
the same date of service, a code from Observation or Inpatient Care Services (Including Admission
and Discharge Services) would be selected.
3. During a soccer game, Ashley, a 26-year-old female, heard a popping sound in her knee.
Her knee has been unstable since the incident and she decided to consult an orthopedist. She
visits Dr. Howard, an orthopedist she has not seen before, to evaluate her knee pain. Dr.
Howard's diagnosis is a torn ACL. From what category or subcategory of evaluation and
management code would be selected for the visit to Dr. Howard?
ANS: Office visit, new patient
,Rationale: Consultations performed at the request of a patient are coded using office visit codes.
Because the patient has not seen Dr. Howard before, this would be considered a new patient visit.
4. The patient is seen in the nursing home today for a follow up of his hospitalization for
pneumonia. He was placed back on Singulair® and has been improving with his breathing
since then. What is the level of history?
ANS: Problem focused
5. Emergency Department
A 47-year-old white male presents to the emergency department after the four-wheeler he was
operating struck a ditch and rapidly came to a halt. This threw him against the windshield
where he struck the mid part of his face and lower lip. This resulted in lip and chin lacerations.
He is evaluated by Dr. Jones and a CT scan suggests a hyper dense abnormality within the
brain. A bleed could not be ruled out and an inpatient hospital admission is recommended.
His past history includes previous tonsillectomy, previous hospital admission for a syncopal
episode associated with pain in the groin area, and hypercholesterolemia. He has no known
allergies. His current medications are Zocor® and Accutane®. He is a non-smoker and a
moderate drinker of alcohol. The review of systems is negative for nausea, vomiting, blurred
vision, or headache. What is the level of history?
ANS: Expanded problem focused
6. Physical Exam:
GENERAL APPEARANCE: Healthy appearing individual in no distress
ABDOMEN: Soft, non-tender, without masses. No CVA tenderness FEMALE EXAM:
VULVA/LABIA MAJORA: No erythema, ulcerations, swelling, or lesions seen. BARTHOLIN
GLANDS: No cysts, abscesses, induration, discharge, masses, or inflammation noted.
SKENE'S: No cysts, abscesses, induration, discharge, masses, or inflammation noted.
CLITORIS/LABIA MINORA: Clitoris normal. No atrophy, adhesions, erythema, or vesicles
noted. Labia unremarkable.
URETHRAL MEATUS: Meatus appears normal in size and location. No masses, lesions or
prolapse.
URETHRA: No masses, tenderness or scarring.
BLADDER: Without fullness, masses or tenderness.
, VAGINA: Mucosa clear without lesions, Pelvic support normal. No discharge. CERVIX: The
cervix is clear, firm and closed. No visible lesions. No abnormal discharge.
UTERUS: Uterus non-tender and of normal size, shape and consistency. Position and mobility
are normal.
ADNEXA/PARAMETRIA: No masses or tenderness noted.
Based on the 1995 documentation guidelines, what is the level of exam?
ANS: Comprehensive
Rationale: Organ Systems: The documentation supports a comprehensive/complete single system
(Female Genitourinary) exam. The level of exam is Comprehensive.
7. Physical Exam:
CONSTITUTIONAL: Vital Signs: Pulse: 161. Resp: 30. Temp: 102.4. Oxygen saturation 90%
GENERAL APPEARANCE: The patient reveals profound mental retardation. Tracheostomy is
in place. EYES: Conjunctivae are slightly anemic. ENT: Oral mucosa is dry. NECK: The neck is
supple and the trachea is midline.
Range of motion is normal. There are no masses, crepitus or tenderness of the neck. The
thyroid gland has no appreciable goiter. RESPIRATORY: The lungs reveal transmitted upper
airway signs and bilateral rales, wheezes and rhonchi. CARDIOVASCULAR: The chest wall is
normal in appearance. Regular rate and rhythm. No murmurs, rubs or gallops are noted. There
is no significant edema to the lower extremities. GASTROINTESTINAL: The abdomen is soft
and nondistended. There is no tenderness, rebound or guarding noted. There are no masses.
No organomegaly is appreciated. SKIN: The skin is pale and slightly diaphoretic.
NEUROLOGIC: Cranial nerves appear intact. The patient moves all 4 extremities
symmetrically. No lateralizing signs are noted. Gross sensation is intact to all extremities.
LYMPHATIC: There are no palpable pathologic lymph nodes in the neck or axilla.
MUSCULOSKELETAL: Gait and station are normal. Strength and tone to the upper and lower
extremities are normal for age with no evidence of atrophy. There is no cyanosis, clubbing or
edema to the digits.
What is the level of exam?
ANS: Comprehensive
