Exam 8: Evaluation and Management EM Services

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?

The code range for Home Services is ____________________.

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

What are the four levels of history type?

An initial inpatient consultation with a detailed history, detailed exam, and MDM of low complexity. CPT Code: ____________________

Match each term with the correct statement below. -timing

When a physician performs a preventive care service, the extent of the exam is determined by the:

CLINIC NOTE CC: Patient presents for routine examination SUBJECTIVE: Sally is a 42-year-old female patient who presents today for a routine physical examination. 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. ASSESSMENT: 1. Normal BP. 2. Normal pelvic exam. Normal pelvic exam. PLAN: Return in 1 year or as needed. CPT Code: ____________________

Match each term with the correct statement below. -quality

Match each term with the correct statement below. -location

The level of E/M service is based on:

According to E/M guidelines, a(n) ____ exam encompasses a complete single-specialty exam or a complete multisystem exam.

These elements would be part of the ____ history: employment, education, use of drugs.

CHART NOTE CC: Dizziness SUBJECTIVE: This 46-year-old female established patient presents today reporting feeling ill yesterday, and she has developed some dizziness. She feels like things stick in her throat and that her throat is "sticky." She has a past history of hypothyroidism and taking Synthroid 0.125 mg q day. Her last TSH was last year and the level appeared to be normal at 0.49. OBJECTIVE: The patient appears to be in good health and in good spirits. Her BP is 120/81. Afebrile. HEENT normal. Neck is supple. No palpable masses are noted. No thyromegaly, tenderness, or nodes. TSA is elevated at 9.9. ASSESSMENT: Hypothyroidism (MDM was low). PLAN: Increase Synthroid to 0.15 mg q day. Recheck in 2 months. CPT Code: ____________________

Subjective: This 17-year-old patient presents to the emergency department after racing motorcycles earlier today. He had his helmet on as well as all of his racing gear. He actively races motorcycles and has done this all summer long, winning a number of times. He came over a jump and lost control of the bike, going over the handlebars. He denies hitting his head but landed on his left elbow and his left knee and has had some discomfort in these areas since. He tells me that he was not going fast, approximately 30 mph. He denies any loss of consciousness. The main complaints center only on the left knee and the left elbow. Objective: The patient is in no acute distress, nontoxic appearing. During an expanded problem-focused examination, he is alert and oriented. Eyes: PERL, EOMI conjugate without nystagmus. Funduscopic exam reveals the discs to be sharp and the TMs normal. Throat: clear with teeth intact. Neck: nontender. No palpable discomfort or adenopathy. He has intact clavicles. Lungs: clear. Heart: regular rate and rhythm. Abdomen: soft; no hepatosplenomegaly, rebound, or guarding. He has good upper- and lower-extremity strength. His right arm is nontender to palpation. The left arm has a small amount of tenderness around the elbow joint, but there is no obvious deformity and he does have good, active motion. He has no tenderness with movement of the hips and no tenderness down the long bones of the lower extremities. There is mild tenderness at the left knee. The knee is intact with negative drawer sign and minimal tenderness along the lateral collateral ligament region. There is no real tenderness along the joint line or over the mediocollateral ligament. Both of these ligaments are intact with stress. X-rays of the left knee and left elbow are negative for fracture. Assessment: Contusion, left elbow and left knee (the MDM was of low complexity). Plan: Ice, Tylenol; recheck if not improving over the next few days, otherwise on a prn basis. CPT Code: ____________________

Match each term with the correct statement below. -context

Location: Emergency Room SUBJECTIVE: This is a 38-year-old female who presents to the emergency room with a history of currently being under treatment for a right corneal abrasion that occurred on Sunday. She states she was seen by the "eye doctor earlier today" and now has a bandage over her eye. Apparently her eye is opened underneath the bandage and she is unable to close her eyelid. She feels her eyelid is stuck to the bandage. OBJECTIVE: She is afebrile with stable vital signs. The patch was removed and there was a folded piece of Telfa that had slipped down and her upper eyelid was unable to close over the top of this. The Telfa was removed and a wet patch was placed. This did provide significant comfort. Her eye patch was reinforced. ASSESSMENT: 1. Right corneal abrasion under treatment. 2. Eye patch replaced as described above. PLAN: She has a follow up visit tomorrow morning with ophthalmology. I told her she needs to keep that appointment. She is to return here sooner if she is having increasing problems. CPT Code: ____________________

A 40-year-old established patient presents to the physician office for a preventive care exam. CPT Code: ____________________

Medical decision making (MDM) is based on the ____ the physician must consider about the management of a patient's condition.

The _______________ is a statement describing the reason for the encounter and is a history element.