Exam 11: Evaluation and Management EM Services

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The level of E/M service is based on:

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The term used to describe a patient who has NOT been formally admitted to a health care facility is ____________________.

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

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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: ____________________

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Match each term with the correct statement below. -duration

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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: ____________________

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

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