A four year old female established patient received Evaluation and Management Services, which
included a problem focused history, an expanded problem focused exam, and medical decision
making of a low level. The pati
...
A four year old female established patient received Evaluation and Management Services, which
included a problem focused history, an expanded problem focused exam, and medical decision
making of a low level. The patient is diagnosed with influenza. Ans- 99213
A 16 year old outpatient who is a new patient to the office complans of severe facial acne. The
history and physical examination are expanded problem focused. The physician must consider
related organ systems in addition to the integumentary system in order to treat the condition.
With minimal number of diagnoses to consider and the minimal amount of data to review, the
physicians decision making is straightforward with regard to the treatment of this patient. Ans99202
A patient was in an automobile accident and is complaining of a minor headache and no other
apparent injuries. HIstory gathered from the bystanders states that the patient was not wearing a
seat belt and hit his head on the windshield. A 15 minute loss of consciousness was noted. The
patient was then admitted for 24 hour observation to rule out head injury. A comprehensive
history and exam are performed by the physician. The MDM is of moderate complexity. Ans99219
A 55 year old female came in with the complaint of severe abdominal pain. The patient was
admitted on 05-07 for observation due to the severity and location of her pain. The admitting
physician performed a comprehensive history and a detailed examination and documented
medical decision making of a moderate complexity given the amount of possible diagnoses,
including appendicitis, gastric ulcer, cholelithiasis and pyelonephritis. Various diagnostic tests
were ordered and done, including barium enema, upper gastrointestinal endoscopy, and KUB
(kidneys, ureters, bladder) x-ray. No disease or disorder was found, and the patient was
discharged from observation on 05-08. The patient reported a decrease in her pain after 30 hours
of IV analgesics and antispasmodics. The physician documented that the patient should follow
up with her primary care physician in 2 days or return to the hospital if the pain worsens. The
physician also documented a final detailed examination of the patient and dictated a discharge
summary report. Ans- 99218, 99217
A 50 year old female patient was admitted to the hospital on 10-10 with a diagnosis of
pneumonia due to Staphylococcus aureus, at which time she received level 2 E/M services from
her attending physician. On 10/11 and 10/12 the patient received level 2 E/M services. On 10/13,
the patient was dischared from the hospital in improved condition to follow up with the
physician at home; the physician spent 30 minutes performing discharge day management
functions. Ans- 99222, 99232, 99238, 99238
An established patient is seen in the hospital on day two of his hospital stay. The patient had
been admitted through the emergency department with status asthmaticus and had been
undergoing extensive respiratory therapy over the past 24 to 30 hours. The physician performs a
detailed interval history and a detailed physical exam. The possibility of pneumonia
complicating the asthma must be considered. The patient's respiratory condition is still unstable.
The MDM complexity was high. Ans- 99233
A 52 year old patient was sent to a surgeon for an office consultation concerning hemorrhoids.
An expanded problem focused history and examination were performed. The consultant
recommended treating with medication after a straightforward MDM. Ans- 99242
A 13 year old male was admitted yesterday for a tympanotomy. Postsurgically, the child
developed fever and seizures of unknown origin. A pediatric consultation was requested. This
was done on the 2nd hospital admission day and 24 hours after surgery. The history of present
illness (HPI) was extended with a complete review of systems (ROS). A complete
past/family/social history (PFSH) was elicited from the mother as part of a comprehensive
history. A comprehensive examination was conducted on all body areas and organ systems. The
MDM complexity was high. Ans- 99255
A patient in the emergency department has a tempuerature of 103 degrees F and is in acute
respiratory distress. Symptoms include shortness of breath, chest pain and gasping. The
physician is unable to obtain a history or perform a comprehensive physical exam because the
patient's condition is critical. The MDM complexity is high. Ans- 99285
With 2 way communication, the physician directs the emergency medical technicians (EMTs) in
an ambulance en route to the emergency department with a patient in apparent cardiac arrest.
Ans- 99288
A patient presents with the complaint of hematemesis. The patient also has a rapid pulse rate and
low blood pressure. In the ED, critical care is provided by the ED attending to raise the patient's
blood pressure and decrease blood loss. This is done for 70 minutes before the patient is
transferred to the surgical suite for an endoscopic procedure to evaluate his esophagus. The ED
physician also documents a detailed examination and MDM of high complexity. Due to the
medical condition, he is unable to provide any history; no family is present to provide
information. Ans- 99284-57, 99291
A physician is called to the intensive care unit to provide care for a patient who received second
and third degree burns over 50% of his body due to a chemical fire. The patient is in respiratory
distress and is suffering from severe dehydration. The physician provides support for two hours.
Later that day, the physician returns and provides an additional hour of critical care support to
the patient. Ans- 99291, 99292, 99292, 99292, 99292
A 72 year old patient suffered a cerebral vascular accident (CVA). Today, the patient is admitted
to a skilled nursing facility (SNF) for rehab and medical care. The patient was just discharged
from an acute care facility. The SNF medical director documents a comprehensive history,
including the patient's chief complaint of paralysis and weakness, an extended HPI, and a
complete ROS. A detailed exam of the patient's cardiovascular, respiratory, muskuloskeletal,
neurological and genitourinary systems is documented. The physician orders a multidisciplinary
rehabilitation care plan for the patient and the continued treatment of the patient's other medical
conditions, including hypertension and diabetes. The MDM complexity is high. Ans- 99304
Subsequent follow-up care is provided for a comatose patient transferred to a long term care
center from the hospital two days ago. The resident shows no signs of consciousness on
examination but appears to have developed a minor upper respiratory tract infection with a fever
and rales heard on ausculation. The physician performs an expanded problem focused history
and a problem focused interval examination with respiratory status and status of related organ
systems such as cardiovascular. The physician is concerned that the respiratory infection could
progress to pneumonia and orders the appropriate treatment. The MDM complexity is moderate.
Ans- 99308
A new patient diagnosed with mild inte
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