These elements would be part of the ____ history: employment, education, use of drugs.
Bruising would be an element of review of this organ system.
The level of E/M service is based on:
key components, documentation, and contributing factors
The HPI must be documented in the medical record by:
The examination is the ____ portion of the E/M service.
The Hospital Inpatient Services subsection is used for patients admitted to:
an acute care facility
The request for advice or opinion from one physician to another physician is this type of service:
Critical care codes are reported based on:
When a physician performs a preventive care service, the extent of the exam is determined by the:
According to information in 99468, what is the age of a neonate?
28 days or younger
The physician must consider multiple diagnoses and management options. There is a moderate amount of data to be reviewed and the risk of complications or death is moderate. What is the level of MDM?
What CPT code is assigned to an ED service that has a detailed history and exam with a moderate level of MDM?
This is a 15-year-old girl, never seen at this clinic. During a problem-focused history, she states that she noticed a lump on the back of her right wrist yesterday.
Problem focused exam: There is a 2-cm freely movable, rubbery, round swelling on the dorsal surface of the right wrist. Distal neurovascular and tendon exam intact. This is not painful to palpation. (The MDM was of straightforward complexity.)
NOTE: Problem focused exam focuses on one problem. This physician examined the swelling in the wrist only.
Impression: Ganglion cyst, right wrist.
Treatment: Refer to Dr. Andrews for further treatment.
A new patient presents to the physician’s office at which time the physician provides a comprehensive history and exam with a high complexity MDM.
An initial inpatient consultation with a detailed history, detailed exam, and MDM of low complexity.
A 40-year-old established patient presents to the physician office for a preventive care exam.
History and exam of the normal newborn infant born in a hospital setting.
A 7-year-old female established patient presents to the pediatrician complaining of ear pain x 3 days. A detailed history is then taken. She had associated fever of 101° F yesterday. Mom treated her with Tylenol. The fever this AM is 99° F. She has had some chills and cough as well as some difficulty breathing. No nausea or vomiting. No prior history of Otitis. Brother was sick earlier this week. The physician performed a detailed exam of the ENT as well as a limited exam of GI, Lungs, and Heart. Vital signs were taken in the office. The physician diagnosed the patient with Otitis Media and an Upper Respiratory Infection and prescribed an antibiotic. The MDM is stated to be moderate.
CC: Patient presents for routine examination
SUBJECTIVE: Sally is a 42-year-old female patient who presents today for a routine physical examination. She was seen last year and her exam was normal.
OBJECTIVE: BP 120/80. Pelvic exam: normal external genitalia. Vagina without discharge except for a scant amount of white discharge that appears normal. Cervix: Multiparous, clear. Bimanual exam is unremarkable. All systems are within normal limits.
1. Normal BP.
2. Normal pelvic exam.
PLAN: Return in 1 year or as needed.
Dr. Martin provided 1 hour and 20 minutes of critical care services to Jack Smithton (age 64), who is in the Intensive Care Unit with acute respiratory distress syndrome. (Separate the codes with two hyphens in your response as follows: 00000 x 0–00000 x 0)
99291 X 1–99292 X 1
Donald Mayors is a homebound patient who is experiencing some new problems with managing his diabetes. Dr. Martin, who has never seen this patient before, drives to Donald’s residence and spends 20 minutes examining the patient and explaining the adjustments that are to be made in the insulin dosage. Dr. Martin performed a problem-focused exam, the history was problem focused and medical decision-making was straightforward.
Modifier ____________________ is used to indicate that a separately identifiable E/M service was performed by the same individual on the same day as the preventive medicine service.
A 90-year-old patient is admitted in congestive heart failure and exacerbation of her COPD. She is now in respiratory failure and renal failure. The patient is intubated and unconscious; 160 minutes of critical care was spent at bedside and coordinating care for this patient. (Separate the codes with two hyphens in your response as follows: 00000 x 0–00000 x 0.)
99291 X 1–99292 X 3
Dr. Smith asks Dr. Wright to see his patient in consultation again on the third hospital day. Dr. Smith’s patient has been experiencing severe headaches since Dr. Wright prescribed an anti-depressant medication for his patient. A problem-focused history and examination and low-complexity medical decision making was made after seeing the patient. Dr. Wright decided to change the patient’s medication.