Exam 8: Evaluation and Management EM Services

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. CPT Code: ____________________

Critical care codes are reported based on:

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. P/E: 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.) Impression: Ganglion cyst, right wrist. Treatment: Refer to Dr. Andrews for further treatment. CPT Code: ____________________

Match the following examination types to the correct examination description. -comprehensive

Label the following as body area (BA) or organ system (OS). -skin

Label the following as body area (BA) or organ system (OS). -eyes

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. CPT Codes: ____________________, ____________________

CHART NOTE CC: This established patient presents to the office today with complaints of rectal bleeding and itching of 2 weeks' duration. OBJECTIVE: This is a 50-year-old male in apparent good health. His BP is 119/78. Rectal examination showed a grade 1 hemorrhoid in the 2 o'clock position approximately 2 cm across. The area around the hemorrhoid was slightly inflamed and a small amount of blood was noted. ASSESSMENT: Hemorrhoid. PLAN: Discussed conservative treatment options with the patient and explained surgical option. He wants to try the more conservative approach of stool softeners, warm and sitz baths. I discussed with him the importance of improved bowel habits. He is to return for a recheck in 2 months. The medical decision making was of straightforward complexity. CPT Code: ____________________

What are the three contributing factors?

What CPT code is assigned to an ED service that has a detailed history and exam with a moderate level of MDM?

The four types of patient status are: ________________, ___________________, ________________, and ____________________

The examination is the ____ portion of the E/M service.

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. The medical decision making is straightforward. CPT Code: ____________________

Match each term with the correct statement below. -duration

Mr. Smith presents to the Emergency Department at the local hospital for chest pain and is seen by the ED physician on duty. The physician obtains an extended HPI, an extended ROS, and a pertinent PFSH. What is the level of history?

An established patient is one who has received professional service from the physician or another physician of the exact same specialty and subspecialty in the same group within the past ____________________ years.

Match the following examination types to the correct examination description. -problem-focused

The physician performs an extended exam of the affected body areas and related organ systems. What is the level of the examination?

This patient is seen in the clinic at the request of Dr. Jones for evaluation of suprapubic pain. Patient is a 22-year-old black female G1 P0, LMP 12/20/xx, EDC 10/16/xx by 14-week ultrasound taken on 4/16/xx, 18 weeks with twin gestation. Presents with complaint of suprapubic sharp to mild pain with onset 2 months ago. Pain has become progressively worse. Patient has been seen by Dr. Jones for this pregnancy and has also been seen by Dr. Smith for this current complaint 2 weeks ago. Patient denies urgency and frequency of nocturia, denies hematuria, and denies discharge. Labs: CBC and urinalysis performed. Allergies: none. Past medical history: genital wart 1986. Past surgical history: wart removed by laser 1986. Social history: no smoking, illicit drugs, or alcohol. PE: During an expanded problem-focused examination, the HEENT was found to be normal. FHT: A 148, B 146. Heart: normal. Lungs: CTA. Abdomen: gravid 20 cm. Slight tender suprapubic region. Vaginal exam: closed cervix, thick, long; no discharge. Extremities: negative for edema; UA loaded with bacteria and WBC. Impression: 1. IUP at 18 weeks with twin gestation. 2. Acute UTI (the MDM was straightforward). Recommendation: Keflex, 500 mg, and follow-up with Dr. Jones. CPT Code: ____________________

The HPI must be documented in the medical record by: