Exam 11: Evaluation and Management EM Services

History and exam of the normal newborn infant born in a hospital setting. CPT Code: ___________________

Identify as body (BA) or organ system (OS): back

Identify as body (BA) or organ system (OS): respiratory

The request for advice or opinion from one physician to another physician is this type of service:

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

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

A 7-year-old female established patient was seen by pediatrician complaining of ear pain x 3 days.A detailed history is then taken.She had associated fever of 101 $\degree$ F yesterday.Mom treated her with Tylenol.The fever this AM is 99 $\degree$ 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. CPT Code: ____________________

Identify as body (BA) or organ system (OS): skin

This is a 79-year-old right-handed married female, who I am now hospitalizing for evaluation of recurrent episodes of numbness and weakness of left upper extremity. This patient relates to having two episodes occurring during the last week of June; both of these occurred while she was eating breakfast around 7:30 AM.She developed sudden onset, without warning, of complete paralysis as well as numbness of the left arm, which lasted for 10 to 15 minutes.There was no speech impairment, no involvement of the face or leg, and no associated headache.These symptoms completely returned to normal.She denies associated chest pain, shortness of breath, or tachycardia with these spells, and there was no jerking of the extremities.About 2 days later, she again had a similar spell.She has not had any further episodes since that time. Patient's history is significant for hypertension since age 35.She had no previous history of heart disease or diabetes.Two years ago she was seen by Dr.Smith for left putamen hemorrhage.Patient was also found to have right meningioma arising near the petrous region.She describes about 8 episodes over the past 10 years when her right peripheral vision blacked out briefly.She could not recall whether either eye was affected or if this was the right peripheral vision.The last such episode was about 4 months ago. This past winter she also had about a 2-week period when the right foot seemed to drag.There has been no recent head injury, and there is no prior history of seizures. Recent carotid Doppler study performed showed moderate calcified plaque in the right carotid bulb but no significant lesion.No flow could be found in the left internal carotid artery, suggesting left internal carotid artery occlusion.Calcified plaque was also noted in the left carotid bulb.Repeat CT scan of the head again showed the old area of infarction involving the left basal ganglia.There was an enhancing lesion starting in the right tentorial region and extending upward into the right parietal area, having the appearance of a meningioma.This is basically unchanged from the previous scan. CPT Code: ____________________

Select the three contributing factors.

The code range for Home Services is ____________________.(Make sure to include a dash with no spaces in your code range.XXXXX-XXXXX)

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

Match each term with the correct statement below. -associated signs and symptoms

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.

Select the four levels of history type.

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

Critical care codes are reported based on:

Select the three elements that complexity of medical decision making is based on.

Bruising would be an element of review of this organ system.

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: ____________________