Exam 11: Evaluation and Management EM Services

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

Select the three key components that are present in every patient case, except counseling encounters or time-based codes, and enable the coder to choose the appropriate level of service.

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

Match each term with the correct statement below. -modifying factors

Match each term with the correct statement below. -context

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.

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?

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

Location: Emergency Room SUBJECTIVE: A 32-year-old female who presents to the emergency department with chief complaint of increased postoperative swelling.This patient had right neck lymph node biopsy done 3 days ago.Patient has a dressing in place ever since then.For the past 24 hours, she feels like she has increased swelling and she presents now because of it.She denies any accompanying fever, chills, or sweats. PAST MEDICAL HISTORY: No known drug allergies.Only surgery was wisdom tooth extraction 1 month ago and then the recent lymph node biopsy.Medically, she has a history of depression. REVIEW OF SYSTEMS: Respiratory: She denies dyspnea. OBJECTIVE: This is an alert 32-year-old female who appears to be in no acute distress.Temperature is 35.7, pulse 90, respirations 18, blood pressure 144/105, oxygen saturation 99%.HEENT: Conjunctivae and lids normal.Mouth well hydrated.Pharynx normal.Neck is supple.I have removed the dressing.There is a Pen Rose drain in place.The wound seems to be healing well.There is some soft tissue swelling which extends about 3 cm from the wound itself.There is no erythema and no warmth to the area. ASSESSMENT: Postoperative swelling. PLAN: I have discussed the case with the ENT surgeon.We have redressed the area.Patient is reassured and will be following up with her doctor tomorrow for drain removal. CPT Code: ____________________

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

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. PLAN: Return in 1 year or as needed. CPT Code: ____________________

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.(Make sure to include a dash in front of your modifier answer.-XX)

DIALYSIS PROGRESS NOTE LOCATION: Inpatient, Hospital PATIENT: Gloria Baxter ATTENDING PHYSICIAN: Ronald Green, MD This patient is continuing on CAPD.Her weight has fluctuated to some extent dependent on some GI losses.She has not been ultrainfiltrating aggressively, but she has not been eating well either.Over the last day or so she has had problems with hypotension, related to perhaps initially bradycardia and then subsequently to recurrence of atrial fibrillation with a more rapid rate.She did drop her weight to 154, and we have given her some saline boluses through the night.This morning she is reasonably stable.Her weight is 158 pounds.She has no congestive failure and no pain.Her abdomen is soft.Fluid clear.Cultures have remained negative.She had been on Unasyn coverage because of an elevated white count and suspected sepsis but that has not materialized. The management plan at this time is to discuss a different drug management plan with cardiology to see whether or not she is a candidate for a class III drug in view of the patient's intolerance to digoxin and/or quinidine.She may well tolerate digoxin at a lower dose, but the problem is it is not effectively blocking her ventricular response. The other component of her management will be to interrupt the antibiotic and observe her, and then thirdly she will get esophagogastroduodenoscopy today and a CT of her abdomen tomorrow to try to investigate the true core problem that she has.Finally, we are going to increase her Epogen slightly to try to push her hemoglobin up a little faster and try to keep it over 12.This will be a substitute for her hypoalbuminemia and hopefully will maintain her blood pressure and her organ perfusion a little bit better. This illness is still serious.She is not thriving.She is not eating well, and her prognosis at this point is still extremely guarded.Code level II reaffirmed.(MDM is high complexity.) CPT Code: ____________________

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: ____________________

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 multiple codes with a comma and then a space in your response.XXXXX, XXXXX) CPT Codes: _______________________________________

Select the four levels of medical decision making complexity.

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: ____________________

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

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

CAPD CYCLER DIALYSIS PROGRESS NOTE LOCATION: Inpatient, Hospital PATIENT: Mandy Horton ATTENDING PHYSICIAN: Ronald Green, MD This patient was reasonably stable overnight.She was evaluated empty.She was in no cardiorespiratory distress.Clear lungs, dullness at the bases.A few crackles but otherwise a somewhat irregular heart rhythm this morning.Echocardiogram pending.Abdomen soft.Exit site okay.She was going to be put on CAPD today.This is being done to facilitate some of her studies as we can work this around them.CT is planned for this morning.The CT will be a critical study since we do have significantly abnormal liver function and the question is what could be possibly going on there.She has an esophagitis consistent with herpes or CMV, and the situation could turn ominous depending on the CT results.We are also doing a calorie count to see whether or not we need to consider supplementing her if everything else works out. The dialysis plan today will be to use five 2.5-liter exchanges, three of them being 2.5% and two of them 1.5%.(MDM is moderate complexity.) CPT Code: ____________________