Reference no: EM133137084

Question: What are the E & M codes for the following scenarios? All codes will be from the Evaluation and Management section of the CPT codebook. Look up terms as needed.

Part I:

1. An established patient is seen for worsening of ankle osteoarthritis. The x-ray reports indicate there is a progression of the disease. The physician orders RA panel. The plan of care includes ibuprofen 400 mg, pod, TID, PRN. The patient is to return in two weeks if no improvement. The physician spent 20 minutes with the patient.

2. A 22-year-old woman visits the gynecologist for the first time since relocating from another state last year. The patient wants to discuss contraceptive options with the physician (think Preventive Medicine Services). The physician collects pertinent past and social history related to the patient's reproductive system and performs a pertinent systems review extended to a limited number of additional systems. The physician completes the history with an extended history or her present physical state. A physical exam includes her cardiovascular and respiratory systems with an extended review of her genitourinary system. Given the patient's history of not tolerating certain types of oral contraceptives in the past, the physician's decision-making involves a limited number of management options, all with a low risk of morbidity to the patient.

3. A physician visits a patient on observation status who has severe influenza. The decision is made to admit the patient, whose condition has worsened and who is not responding to the therapy initiated on the observation unit. The physician performs a detailed history and a detailed physical exam to reflect the patient's current status. The patient's problem is of low severity but requires ongoing active management, with possible surgical consultation. The medical decision-making complexity is low.

4. The patient presented to his family practitioner with a sore throat and runny/stuffy nose. The patient had not seen the physician for 3 1/2 years. A complete physical and history was taken. The physical exam is normal. The condition appears to be the common cold. The patient is advised to take OTC medicine for the symptoms and rest. Antibiotics are not appropriate at this time. The physician spent 30 minutes with the patient.

5. Dr. Porter is requested to provide standby service for Dr. White. Dr. Porter provided one hour of standby service without any direct contact with the patient.

6. Dr. Crane goes to the nursing care facility to make a subsequent visit to a patient who is stable and recovering.

7. An established patient presents to the doctor's office to have bandages removed. The service is performed by a nurse, the patient does not see the doctor.

8. A cardiac arrest patient is in the intensive care unit of the hospital (he is critically ill). The patient is in respiratory failure, and the physician spends 2 hours and 30 minutes with the patient.

9. A 40-year-old male patient was sent for a surgical consult by his family physician concerning polyp found in the colon. A problem-focused history and examination were performed. The consultant recommended surgical removal of the polyp.

10. John Taylor is a 16-year-old outpatient who is a new patient to the office. John complains of severe facial acne. The history and physical exam are expanded
problem-focused. The physician must consider related organ systems in addition to the integumentary system in order to treat the condition properly. With a minimal number of diagnoses to consider and a minimal amount of data to review, the decision-making is straightforward

11. Mrs. Wilson, a new patient, is seen by the physician in the skilled nursing facility for an initial nursing facility assessment. Mrs. Wilson recently suffered a cerebral thrombosis with residual dysphagia and paresis of the left extremities She was transferred from the acute care hospital to the skilled nursing facility for concentrated rehabilitation. Mrs. Wilson also has arteriosclerotic heart disease with a permanent pacemaker in place, rheumatoid arthritis, urinary incontinence, and macular degeneration in her right eye. The physician, who did not know Mrs. Wilson prior to her transfer, performs a comprehensive history and physical exam. Given the patient's multiple diagnoses and the moderate amount of data the physician has to review, the medical decision-making is on a high level of complexity.

12. A third-party payer sought consultation for confirmation about a patient's ability to return to work after the removal of a subdural hematoma two months previously. The patient's primary physician had stated that the patient was not yet able to return to his employment, and the third-party payer wanted a second opinion. The patient stated that he continued to have severe and incapacitating headaches and was unable to return to work. A comprehensive history and physical exam were performed in the office. The medical decision-making was of moderate complexity, based on physician findings.

13. Initial office visit for a child with chickenpox. The physician spends 10 minutes with the patient.

14. The physician provides an initial intensive care service for the evaluation and management of a critically ill newborn (5 days old) inpatient for one day.

Attachment:- Initial intensive care service.rar