# CEMC practice exam from the AAPC



## LLovett (Jun 5, 2009)

I just got the online exam this week. Case 28 I answered that is was a 99214, when I hit grade it tells me I am wrong. I read the rationale.

HISTORY LEVEL IS DETAIL
EXAMINATION LEVEL IS DETAILED
MEDICAL DECISION MAKING LEVEL IS LOW


Source: The E&M Documentation Guidelines can be referenced at: http://www.cms.hhs.gov/MLNEDWebGuide/25_EMDOC.asp

That was their rationale.

On the bottom of every note it states 

The AAPC does not ask a coder to make any final determination based on medical necessity.  Decisions about what constitutes a medically necessary service should be made only by a practicing physician peer.  Please code this service based solely on the elements of History, Exam and Medical Decision Making using the same rules and logics that are defined by the “Marshfield Clinic” audit tool, and CPT coding guidelines

Ok, what am I missing? 

Thanks,

Laura, CPC


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## dmaec (Jun 5, 2009)

was this a new patient level 3 - 99203?  or what was their answer??


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## LLovett (Jun 5, 2009)

They are saying 99213.

Laura, CPC


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## dmaec (Jun 5, 2009)

hmm...well, I'd agree with you (given what you wrote), I would have chosen the 99214 also, although I know there's always the arguement that MDM drives the level. 

I don't have a link to where it states that but I've seen it said many times.. 
*shrugs*  sorry I'm not much help - but I agree with what you picked!


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## LLovett (Jun 8, 2009)

Thanks Donna.

I just copied and pasted the rationale info they gave me. This kind of stuff makes me nervous about taking the exam next month. The fact that they gave me an audit tool to use that combines 95 & 97 history with only 95 exam doesn't make me feel any better either. I have emailed the AAPC asking why they are giving out incorrect information but I have not recieved a response. If they base scenarios in the exam on the mixing of the guidelines like the audit tool I won't be getting those questions right.

Laura, CPC


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## Sarahbellum (Jun 8, 2009)

Please keep us posted about the reply you get from the AAPC.

Sarah


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## dmaec (Jun 8, 2009)

Laura - I think you'll do just fine on the test nonetheless. ..BUT I do understand your frustration!! 
let us know their answer..


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## rthames052006 (Jun 8, 2009)

katmryn78 said:


> Thanks Donna.
> 
> I just copied and pasted the rationale info they gave me. This kind of stuff makes me nervous about taking the exam next month. The fact that they gave me an audit tool to use that combines 95 & 97 history with only 95 exam doesn't make me feel any better either. I have emailed the AAPC asking why they are giving out incorrect information but I have not recieved a response. If they base scenarios in the exam on the mixing of the guidelines like the audit tool I won't be getting those questions right.
> 
> Laura, CPC



I felt your pain, I too purchased the practicum, the only thing I could think is that they put both 95 and 97 History DG is so that once you know which one your using for history you then know what exam DG's you will need.  It took me some time to get used to using the audit tool they provided, but you don't have to use the audit tool they have given us you can use whichever audit tool you want, I took the one they gave plus the one I use on a regular basis but for me since I did the practice exam using the one they provided I did stick with using it for the exam too.


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## LLovett (Jun 8, 2009)

*Just got a response from AAPC*

"The quick reference tool is to be used in conjunction with the 1995 and 1997 Documentation Guidelines. Since the 1997 Documentation Guidelines include the templates for the 1997 exam component, we did not reproduce them on the quick reference tool. 

The recommended resources for the exam we have posted on the website include:

Highly Recommended References:

E/M Audit Worksheet of your choice  
Both CMS DGs (1995 & 1997) 
If you prefer to use a different audit tool that has both 95 and 97 exam components, you can instead of using the tool we provide in addition to the exam templates included in the 1997 Documentation Guidelines. It was not our intention with the tool for you to mix and match guidelines. On the tool it is labeled as "95 exam guidelines" so that it is clear that it is not to be used for the 1997 exam component. In the one hour E/M audio, we cover that you are not to use 95 and 97 guidelines for the same note and that you should use both the 1995 and 1997 Documentation Guidelines when preparing for and sitting for the exam. There are many specialties included in the exam. It would be impossible to include the template for each specialty on the quick reference tool. That is why we instruct you to also bring both sets of guidelines with you to the exam.



The correct E/M code selection for Case 28 is 99214. The rationale provided is correct based on the documentation in the note. The answer key was mismarked on the website. Thanks for bringing it to our attention."

The above is the email I got back. I have not listened to any of the audio portions yet, I just took the test to see where I was. I missed 8 (1 of them was this one) out of 75. Some of the questions threw me because they really don't have anything to do with E/M they were about insurance/CMS processing and reasons for audits. 

Oh well, I guess I have a better idea what to expect.

Laura, CPC


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## dmaec (Jun 8, 2009)

yup...and then there's that - .... a mistake...   it happens, all the time.  At least you brought it to their attention! AND more so, you were correct! 

there's always a risk of error in our books/answers that we use.  So if something just doesn't sit well, doesn't make sense (like this one), it's good to question it! 

we're all human, we all make mistakes!


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## LLovett (Jun 8, 2009)

Very true. 

Unfortunately I have found another error in the practice test. I have another email into them.

This is really causing me concern.....What happens if the real exam has these kinds of errors? How do you fight that? I guess you can write notes in the test book but how do you follow up with that?

Part of me says settle down and let it go but that goes against everything in me. I take this very seriously plus I put out $345 of my own money for the practicum and exam.

Laura, CPC


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## coder21 (Jun 8, 2009)

If you dont mind me asking what was the other mistake you found?


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## LLovett (Jun 9, 2009)

Case 19

If this patient later became critically ill and her nephrologist subsequently spent 75 minutes bedside providing life supporting activities, what code/s would be appropriate by the nephrologist?


A. 99291 
B. 99292 
C. 99291, 99292  
D. None of these 

I responded A. 99291. It said I was wrong and the answer is C. 

I kind of went along with it even though I didn't think it was right, figuring I need to do some research on the matter. Then I listened to one of the audios that goes with the course. Plain as day it confirmed what I thought was in fact correct, you have to have at least 15 minutes over 74 in order to charge 99292. I emailed them back and they responded the test was wrong and they were changing it.

Laura, CPC


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## Anna Weaver (Jun 9, 2009)

Laura,
That was a good catch. CPT book could be a little clearer, but here's what CPT assistant had to say:

Code 99292 is used to report each additional 30 minutes beyond the first 74 minutes.  It also may be used to report the final 15-30 minutes of critical care on a given date.  Critical care of less than 15 minutes beyond the first 74 minutes or less than 15 minutes beyond the final 30 minutes is not reported separately.


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## Karolina (Jun 9, 2009)

This may be very borderline to defend. It looks like it's one of those questions designed to "trick" you. They seem to go strictly by the table printed in the CPT book. It would be interesting to see their reply. 
Please keep posting updates.
Thanks!


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## FTessaBartels (Jun 9, 2009)

*Answer C is correct*

If you look in 2009 CPT Professional Edition, page 19 there is a table with times and appropriate codes.

75-104 minutes is coded as 99291 x1 AND 99292 x1

You have to have at least 15 minutes over the first hour (i.e. 75 minutes). That is why 74 minutes is still considered the first hour.

F Tessa Bartels, CPC, CEMC


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## rthames052006 (Jun 9, 2009)

FTessaBartels said:


> If you look in 2009 CPT Professional Edition, page 19 there is a table with times and appropriate codes.
> 
> 75-104 minutes is coded as 99291 x1 AND 99292 x1
> 
> ...



When I took the CEMC that question was on the test and I answered using #C also.


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## LLovett (Jun 10, 2009)

*Answer C is not correct per the AAPC*

According to the audio and slides provided by the AAPC for the CEMC course it is not correct. Also the AAPC responded to me they had the answer key marked incorrectly and have since updated it to show the answer should be A. 99291.

This is based on CPT assistant, which Anna posted what it says.

Laura, CPC


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## RebeccaWoodward* (Jun 10, 2009)

I'm curious...does this mean that the questions on the test (And I'm *not* looking for specific examples) were also incorrect?  Is there a possibility that those who have already taken the exam were faulted for correct answers?


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## LLovett (Jun 10, 2009)

That is my fear too, Rebecca. 

Laura, CPC


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## RebeccaWoodward* (Jun 10, 2009)

Interesting.  So...Let's say you had not detected these errors and the errors weren't reported......If the individual taking the exam based their answer on the provided answer (incorrect answer), who is held accountable and how does this become rectified?


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## FTessaBartels (Jun 10, 2009)

*I stand by my answer and CPT*



FTessaBartels said:


> If you look in 2009 CPT Professional Edition, page 19 there is a table with times and appropriate codes.
> 
> 75-104 minutes is coded as 99291 x1 AND 99292 x1
> 
> ...



The CPT book is very clear and specific *in the table* referenced in my earlier response.

Go back some years to previous editions of CPT and you'll find that the original description of 99291 was for the "first hour" ... then they started in with the at "last 15 minutes" criteria and began to really muddy the waters. Every time they try to clarify they just cause more confusion. 

In fact, CPT is full of inconsistencies and conflicting information because it has never been written (or edited) by an English major! (Check out all the references to age for the new pediatric critical care codes and you'll see what I mean.)

If you look at the guidelines and explanation for prolonged service codes, which have a similar time-frame requirement, you'll see an explanation (page 26 of 2009 CPT Professional Edition) that includes a phrase "30 minutes beyond the first hour" ... and you'll see a table that is virtually identical to the one for critical care (but with the prolonged service codes). 

If AAPC is changing the exam that is a poor reflection on AAPC. 

F Tessa Bartels, CPC, CEMC


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## Karolina (Jun 10, 2009)

I agree with Tessa - I also was reminded of the prolonged service codes as this discussed unfolded.


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## LLovett (Jun 10, 2009)

http://www.cms.hhs.gov/Transmittals/Downloads/R1530CP.pdf

Top of page 18. Per CMS, less than 15 minutes beyond the first 74 minutes is not separately payable. 

Laura, CPC


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## FTessaBartels (Jun 11, 2009)

*Same reference - look at the table*



katmryn78 said:


> http://www.cms.hhs.gov/Transmittals/Downloads/R1530CP.pdf
> 
> Top of page 18. Per CMS, less than 15 minutes beyond the first 74 minutes is not separately payable.
> 
> Laura, CPC



Same exact reference as Laura cited ... look at the bottom of that same page ... the table clearly shows the same thing that CPT shows.

75-104 minutes is 99291x1 PLUS 99292x1

F Tessa Bartels, CPC, CEMC


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## LLovett (Jun 11, 2009)

So your position is that even though medicare clearly states less than 15 minutes over 74 is not separately payable, that since the chart says 75 minutes it is ok to bill it anyway? 

Sorry, but I'm going with Medicare on this one, I don't want to pay back all that money plus penalties when they have clearly defined what is payable and what is not. 

Because they will pay it if you submit it, then if they audit they will take it back plus a lot more than they paid in the first place.

Laura, CPC


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## Karolina (Jun 11, 2009)

After looking at this page I think what they (Medicare) are saying is that 99292 is billed for each block of up to 30 minutes. If the last block is less than 15 minutes, this cannot be billed. So when they say in the table 75 - 104 minutes they really mean 75 - 104 minutes *if at least 89 minutes were spent*.


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## ARCPC9491 (Jun 11, 2009)

*I agree with Tessa*

The verbage Medicare has in their manual you are referring to is redundant and confusing. Basically what they are saying is in order to use both codes.... 99291 is for the first hour, you need to have a fraction of 15 in order to use 99292 for the final time. So for example, 75 minutes is 15 minutes above the first hour, you would code 99291 and 99292.

A simple formula for correct critical care coding as follows:

Total minutes: 197 minus 60 (99291) divided by 30 (determines units of 99292)

Subtract the first hour from your total, you have a 99291 and 137 minutes remaining. 137 / 30 is 4. Your remaining minutes is 17. Therefore, it would be appropriate to code 99291 and 99292 x 5.

Hope that helps.


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## RJimenez (Jun 11, 2009)

I would like to thank everyone for their discussion on this topic and providing their sources. Our expert advisors are split on the proper code selection. Below is a summary of information from CMS, CPT Assistant and the CPT manual. 

According to 100-04 Medicare Claims Processing Manual Chapter 12 - Physicians/Nonphysician Practitioners 30.6.12 - Critical Care Visits and Neonatal Intensive Care (Codes 99291 - 99292)

Page 66

“The CPT code 99291 is used to report the first 30 - 74 minutes of critical care on a given calendar date of service. It should only be used once per calendar date per patient by the same physician or physician group of the same specialty. CPT code 99292 is used to report additional block(s) of time, of up to 30 minutes each beyond the first 74 minutes of critical care (See table below-the same as in CPT®). Critical care of less than 30 minutes total duration on a given calendar date is not reported separately using the critical care codes. This service should be reported using another appropriate E/M code such as subsequent hospital care.

http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf

The same information is also provided in the revised transmittal which notes an error provided in the 1530 Transmittal regarding critical care time. 

http://www.cms.hhs.gov/Transmittals/Downloads/R1548CP.pdf

The most recent information provided by CMS supports using 99291, 99292 for 75 minutes of critical care time.

The information provided in CPT Assistant is as follows:

November 1999 CPT 2000 Code and Guideline Changes: A Comprehensive Review

 “Code 99292 is used to report each additional 30 minutes beyond the first 74 minutes. It also may be used to report the final 15-30 minutes of critical care on a given date. Critical care of less than 15 minutes beyond the first 74 minutes or less than 15 minutes beyond the final 30 minutes is not reported separately.”

December 1998 Critical Care Services

“CPT code 99292 is used to report each additional 30 minutes beyond the first hour. It also may be used to report the final 15-30 minutes of critical care on a given date. Critical care of less than 15 minutes beyond the first hour or less than 15 minutes beyond the final 30 minutes is not reported separately.”

The most recent information provided in CPT Assistant supports coding 99291 for 75 minutes of critical care. This is not reflected in the table provided in CPT. 

The coding guidelines in CPT® state “Code 99292 is used to report additional block(s) of time, of up to 30 minutes each beyond the first 74 minutes.” This would support coding 99291, 99292 for 75 minutes of critical care time since the clarification for 15 minutes is not provided. 

We will request clarification from CMS and AMA. 

Thanks,
Rae

Raemarie Jimenez, CPC, CPC-I, CANPC, CRHC
Director of Exam Content
American Academy of Professional Coders
Phone 877-642-9909
Fax 801-236-2258


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## mwatson (Jun 11, 2009)

*CEMC practice exam*

I just purchase the CEMC online practicum, but haven't received a confirmation. Is the online information email to you on how to download the practicum on to a computer or is it shipped to you?

Thanks,

Michelle CPC


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## LLovett (Jun 12, 2009)

It is under My Account, My Items. Everything is online.

Laura, CPC


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## FTessaBartels (Jun 15, 2009)

*Jan 2009 Coding Edge pg 18*



RJimenez said:


> I would like to thank everyone for their discussion on this topic and providing their sources. Our expert advisors are split on the proper code selection. Below is a summary of information from CMS, CPT Assistant and the CPT manual.
> 
> According to 100-04 Medicare Claims Processing Manual Chapter 12 - Physicians/Nonphysician Practitioners 30.6.12 - Critical Care Visits and Neonatal Intensive Care (Codes 99291 - 99292)
> 
> ...



Interestingly enough the January 2009 Coding Edge magazine has an article about Critical Care Coding written by Elin Baklid-Kunz. On page 18 the table that is printed in CPT and that is part of the Medicare guidelines that are so at issue is printed ... 75 - 104 minutes equals 99291 x 1 plus 99292 x 1.

F Tessa Bartels, CPC, CEMC


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## renifejn (Jul 6, 2009)

Has there been any updated news about the discussions of this thread?

thanks


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## skraft1969 (Mar 18, 2017)

*how would we know as the testee*

I am taking my CEMC tomorrow as well and I too had the issue with this question. Based on real world coding I would have picked 99213 however based on the question and the direction given You would have to pick a 99214.
Okay so here is my issue............What if you don't pass the exam and there are questions like this on the test. The AAPC only gives you a score and it's pass or fail. You can't go back and have them give you the rationale for any missed questions and you certainly can't argue your point. 
How does the AAPC handle this?


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