Test Your Auditing Knowledge

Multiple Choice


Using 97 guidelines, what would be the level for this examination?

PHYSICAL EXAM: Weight 172 lb. BP 128/78 P 72. In general she is a well developed well nourished white female. HEENT: Eyes are round and reactive to light and accommodation. Neck – supple. No adenopathy or thyromegaly. Heart RRR without murmur, rub or gallop. Lungs – clear to auscultation bilaterally. Abdomen – soft. She has some diffuse tenderness to palpation, but this is mild. Extremities no cyanosis, clubbing or edema. EKG was normal. Pulse ox normal. Urine dip and Hematocrit are normal.

a. Problem Focused

b. Expanded Problem Focused

c. Detailed

d. Comprehensive


What is the History for the following note using 95/97 guidelines?

Chief Complaint: Cough and Rash

Patient has had a cough for the last week. Initially it was dry. It has been loosening up and and he did have a fever last night. He woke this am again with the fever and a rash that covered his whole body in a lace like pattern primarily to the extemities, abdomen and chest. There was no rash on his back and it did not itch. He tried taking Benadryl but it only made him sleep and the rash was still present. He denies any shortness of breath, congestion, runny nose, chills, sweating. He had had some dizzy spells and a sore throat but it is not severe. He does have a history of sinusitis and continues to smoke.

a. Problem Focused

b. Expanded Problem Focused

c. Detailed

d. Comprehensive


Which answer below is not required for an operative note?

a. Pre-op/Post-op diagnosis, surgeons, any complications, patient name and date of birth

b. Date of surgery, surgical approach, instruments and supplies used, anesthesia used

c. Procedure performed, condition of patient after procedure, consents obtained

d. All of these are required


Using the new 2021 E/M guidelines, what is the correct answer for the following noted. 

22-year-old established male presents to the office for right leg pain. He tripped on some rocks when hiking. He did not have immediate pain but last night he started experiencing severe pain in the right leg and is unable to bear weight. No swelling, discorloration or bruising note. 

Vitals reviewed.  No acute distress, Musculoskeletal: Normal sensation in foot, Normal motion of toes and ankle. Denies tenderness to palpation in the right tibia, some tenderness in right knee and discomfort to fully straightened knee.  Able to stand but cannot bear full weight.  No visible swelling, discoloration or bruising. No tenderness to palpation over distal femur. Skin is warm and dry, minor abrasion overlying right knee. No surrounding erythema or induration.

Diagnosis: Right knee strain 

I ordered an X-ray of knee and reviewed Dr. Thomas radiology report of right knee from Mountain Radiology performed today on 02/08/21. No fracture or other abnormalities noted.  Recommend Tylenol and alternation with ibuprofen every 4-6 hours as needed along with ice or cold packs and elevation as necessary.

a. 99203 - Low problem, 2 Complexity, Low risk

b. 99214 - Moderate problem, 2 Complexity, Moderate risk

c. 99213 - Low problem, 2 Complexity, Low risk

d. Either 99213 or 99214, could support either one


32-year-old female new patient presents with fever, sore throat, congestion, wheezing and shortness of breath. She has a history of asthma and the symptoms started 3 days ago and was sent home from work due to a temp of 101.3. She is using her inhaler and nebulizer every 3-4 hours without relief. She denied any vomiting, diarrhea. Negative for chest pain.  Positive for weakness, fatigue, wheezing, congestion, fever, and shortness of breath. Pulse ox is 91.

Exam: Patient appears anxious, vital reviewed. Oropharynx shows posterior nasal drainage. Heart is regular rate and rhythm. Lungs: Diminished breath sounds with wheezing. Abdominal:Soft, non-tender, non-distended. 

Assessment:  Pneumonia, acute exacerbation of asthma.

Plan: X-rays, CMP and CBC ordered.  Patient has a high white count of 22.7 and x-rays reveil left midlung consolidation which is most suggestive of a pneumonia. I will start her on steroids and she is to return tomorrow for follow-up and instructed to go immediately to the Emergency Room if she has chest pain or progression of shortness of breath.  

Using 2021 E/M guidelines what is the level of the MDM for this encounter?

a. 99204 - Problem - Moderate, Complexity of Data -Moderate, Risk - Moderate

b. 99205 - Problem - High, Complexity of Data Moderate, Risk Moderate

c. 99205 - Problem -High, Complexity of Data, Moderate, Risk High

d. 99214 - Problem-Moderate, Complexity of Data - Limited, Moderate Risk


Per 2021 E/M guideline updates, which answer is FALSE?

a. Pulse Ox cannot be counted as a test

b. If the provider orders a BMP Panel and a Thyroid Test, patient will return next week for the results. The provider can bill for ordering the test and then next visit bill for review of tests.

c. For external review of notes the documentation must identify what was obtained, where and who did the information come from

d. Independent historian is located in Category 2 for 99203/99213 and located in Category 1 for 99204/99214


Per 2021 E/M guidelines Total Time on the date of the encounter can be used. Which answer below correctly identifies what is included in provider time?  

a. Total time on the date of the encounter, ordering tests, education of patient/family or caregiver, nursing time to prepare patient to see the physician, reviewing past history, independent test interpretation if not separately reported

b. Obtaining history, referring to other health care professional, documenting clinical information, care coordination and performance of other services reported separately

c. Care coordination, preparing to see the patient, ordering test, meds, counseling with patient, clinical staff time

d. Counseling and education, appropriate exam, preparing to see the patient, communication with other health care professionals on the same date of the encounter


95 examination is based on Body Areas and Organ Systems. Which statement below identifies an Organ System? 

a. Head, neck, chest

b. Heart, auscultation, carotid bruits

c. Genitalia, groin, abdomen

d. Back, extremities


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