An established patient is defined as,

CPT code 99382 is age related. What is the age range designed in this code. What is the age range designated in this code?

How does CPT apply the term consultation in relation to the provider?

In clinical terms, chief complaint refers to which of the following?

Which of the following distinguishes E/M emergency service coding:

Counseling and coordination of care coding for billing purposes require which one of the following in terms of E/M service patient/provider contact?

Mr.Thomas has got admitted in the hospital on 2/1/2011 by Dr.Jim for Mild heart attack.On the second day 2/2 Jim has requested the cardiologist of the hospital to visit his patient.After evaluating the patient by performing detailed hx,detailed examination & Moderate complexity MDM.The cardiologist has sent a report to Dr.Jim.Which code should the cardiologist report for 2/2/2011(Scenario 1)

Select the purpose of E/M service observation status.

A patient presents to the office with Severe Nausea & Vomiting fo r the first time. After performing EPF history, EPF examination & low complexity MDM, it was decided to admit the patient for observation at 9.30pm.The patient has been continuosly monitored and was discharged at 12.30am.During observation detailed history, detailed exam& Moderate MDM has been performed? What are the CPT codes should be reported by the physician?

A patient presents to the emergency department complaining of a migraine headache which has persisted for two days. The patient also complains of nausea and vomiting. The ED physician performs a detailed history, expanded problem focused exam and arrives at a moderate level of decision making. The physician administers Imitrex to the patient and sends the patient home.What is the correct E/M service for the ED physician?

According to CPT guidelines for critical care services: The physician reports the time spent with the patient when providing critical care services. Where the critical care services must be provided in order to count toward the time reported?

The provider provides subsequent hospital care per day on a newborn. The CPT code is,

The provider provided two hours of critical care for an adult. The correct CPT code is:

The provider discharged a patient from the hospital inpatient unit (admitted day before) in less than 30 minutes. The correct CPT code is:

The provider has admitted a patient for observation & got discharged on the same day. The provider has performed detailed history, detailed examination & moderate complexity MDM .The correct CPT code is:

Inpatient neonatal care code applies to what age of patient?

The provider provides a complex/lengthy telephone call of 20 minutes to a patient regarding the results of his lab work. The correct CPT code is:

The provider provided hospital discharge day management for 65 minutes. How do you code this discharge management?

The nurse saw an established patient in the provider’s office ad checked the patient’s blood pressure. What is the correct CPT code?

The provider admits a two-day-old infant into the NICU and spends 2.5 hours providing critical care. What is the correct way to code this scenario?

A pediatrician performs a history, examination and other newborn care for an infant that was delivered at home by a mid wife. The physician also informs the parents on how to care for the newborn.What code would the pediatrician report for this service?

What is the code for direction of EMS service?

An inpatient is seen in follow-up for pelvic pain by the attending physician five days after admission. The provider performs a problem focused history, expanded problem focused exam and arrives at a moderate level of decision making. What is the appropriate code?

An initial office visit was made by a 16 year old female with a four day history of abdominal pain with occasional vomiting. Mother states the patient has not had fever. A detailed history is obtained. A detailed exam is performed including GI system, GU system with pelvic, chest, heart, lungs and skin. Vaginal and cervical cultures were obtained. She was asked to collect stool specimens for culture over the next few days. Medical decision making is of moderate complexity. Code this scenario.

A 55 year old male patient recently moved to phoenix and is seeing his new internist for the first time. He has had a long history of gouty arthropathy, but he presents today to his new internist’s office for his annual preventive medical reevaluation and management. Patient has been controlled on diet for three years. A comprehensive history and physical is performed and the patient is counseled regarding diet and exercise. Appropriate blood work is ordered. Code this scenario.

A physician spends 20 minutes incorporating speech therapy revisions in the patient’s treatment plan; the patient lives in an assisted living center and was neither present during the time the changes were made nor at the time the physician discussed the revisions with the center’s speech therapist. What is the appropriate code for the physician’s services?

After being called to the emergency room to treat one of his patients suffering from multiple injuries, a provider is asked to examine another one of his patients already registered in the ER, presenting with acute respiratory distress symptoms including a productive cough. The ER is very busy, therefore the ER provider has the patient’s provider see and treat this patient. The provider ordered a CBC and chest x-ray. An expanded history of the present illness was taken, an expanded problem focused examination performed and medical decision making was of moderate complexity. Overall level of medical decision making was moderate. The patient was given a prescription and written instructions for continued home care and told to make an appointment in the office if the symptoms persist. Code the provider’s service for the second patient.

The patient is a 23 year old male who needs a prescription refill for Ventolin tabs and Proventil inhaler. The patient moved here two months ago from Florida. He was diagnosed with asthma at age eight and he says his asthma is well controlled on his current medication regimen. He says he usually uses the inhaler two to four times a week, generally after performing activities like tennis or skating. Px: WDWN male in no acute distress; temp 98.6, pulse 65, BP 110/70; respiration 18; HEENT within normal limits; lungs clear to auscultation, no rales or wheezing. Impression: Asthma stable on present medication Plan: Rx written for three months for current medications; recheck in three months, sooner if problems. Patient was advised to schedule baseline physical upon next visit. According to CPT guidelines, which correctly reports this service?

Mr.Thomas has got admitted in the hospital on 2/1/2011 by Dr.Jim for Mild heart attack.On the second day 2/2 Jim has requested the cardiologist of the hospital to visit his patient.After evaluating the patient by performing detailed hx,detailed examination & Moderate complexity MDM.The cardiologist has sent a report to Dr.Jim.The cardiologist has repeated the same consultation on 2/3/2011 & 2/4/2011.Which code should the cardiologist report for 2/3 & 2/4?

What level of history of present illness (HPI) is the following report? “I saw Mr. Smith at the memorial hospital wound center. He is 85 years old. He comes to me for a wound to his right ankle. It has been present for about 3 months. He was seen at another facility then and had several unsuccessful debridements. He has an Unna boot after getting antibiotics by Dr. James. He is having mild to moderate pain in that region” which is very sharp in nature.

How does the CPT Professional Edition define a new patient?

James, a 35-year-old new patient, received 45 minutes of counseling and risk factor reduction intervention services from Dr. Kelly. Dr. Kelly talked to James about how to avoid sports injuries. Currently, James does not have any symptoms or injuries and wants to maintain this status would you report this.This was the only service rendered. How service?

Andrea, a 52-year-old patient, had a hysterectomy on Monday morning. That afternoon, after returning to her hospital room, she suffered a cardiac arrest. A cardiologist responded to the call and delivered one hour and 35 minutes of critical care. During this time the cardiologist ordered a single view chest x-ray and provided ventilation management. How should you report the cardiologist’s services?

Brandon was seen in Dr. Shaw’s office after falling off his bunk bed. Brandon’s mother reported that Brandon and his sister were jumping on the beds when she heard a “thud.” Brandon complained of knee pain and had trouble walking. Dr. Shaw ordered a knee x-ray that was done at the imaging center across the street. The x-ray showed no fracture or dislocations. Dr. Shaw had seen Brandon for his school physical six months ago. Today, Dr. Shaw documented a detailed examination and decision-making of moderate complexity. He also instructed Brandon’s mother that if Brandon had any additional pain or trouble walking he should see an orthopedic specialist. How should Dr. Shaw report her services from today’s visit?

Adam, a 48-year-old patient, presented to Dr. Crampon’s office with complaints of fever, malaise, chills, chest pain, and a severe cough. Dr. Crampon took a history, did an exam, and ordered a chest x-ray. After reviewing the x-ray, Dr. Crampon admitted Adam to the hospital for treatment of pneumonia. After his regular office hours, Dr. Crampon visited Adam in the hospital where he dictated a comprehensive history, comprehensive examination, and decision-making of moderate complexity. How would you report Dr. Crampon’s services?

Why are the following codes not reported with continuing intensive care services (99478–99480): 36510, 36000, 43752, 51100, 94660, or 94375?

Larry is being managed for his warfarin therapy on an outpatient basis. Dr. Nancy continues to review Larry’s INR tests, gives patient instructions, dosage adjustment as needed, and ordered additional tests. How would you report the initial 90 days of therapy including 8 INR measurements?

Dr. Jane admitted a 67-year-old woman to the coronary care unit for an acute myocardial infarction. The admission included a comprehensive history, comprehensive examination, and high complexity decision-making. Dr. Jane visited the patient on days two and three and documented (each day) an expanded problem focused examination and decision-making of moderate complexity. On day four, Dr. Jane moved the patient to the medical floor and documented a problem focused examination and straightforward decision-making. Day five, Dr. Jane discharged the patient to home. The discharge took over an hour. How would you report the services from day one to day five?

Which code range would describe services for a critically ill patient who is 23 days old as a out patient?

Mr. Johnson, a 38-year-old established patient is being seen for management of his hypertension, diabetes, and weight control. On his last visit, he was told he had a diabetic foot ulcer and needed to be hospitalized for this condition. He decided to get a second opinion and went to see Dr. Myers. This was the first time Dr. Myers had seen Mr. Johnson. Dr. Myers documented a comprehensive history, comprehensive examination, and decision-making of high complexity. He concurred with hospitalization for the foot ulcer and sent a report back to Mr. Johnson’s primary care doctor. How would you report Dr. Myers visit?

How does the CPT Professional Edition define an emergency department?

Lucus, a three-year-old new patient is seen for a well-child examination. The doctor documents an age appropriate history, examination, anticipatory guidelines, risk factor reduction intervention, and indicates Lucus’ immunizations are up to date. How would you report this service?

42-year-old woman is being discharged today, 2/5/XX. She was admitted to the hospital 2/2/XX for acute diverticulitis. Refer to dictated notes for a detailed description of the history, exam, and assessment and treatment protocol. Patient was also seen in consultation by Dr Z. She was placed on intravenous antibiotics and has made slow steady progress. Today has no abdominal pain. Labs are normal and CT of the abdomen and pelvis showed changes consistent with diverticulitis in the left side of colon. She was given follow up instructions of her medications, what diet to have and to follow up with PCP in 10 to 14 days or return if pain resumes. Total time spent with patient 40 minutes. What CPT® code(s) should be reported?

63-year-old man is coming in for a second opinion for his sleep apnea. He has had it for the past five months. Sleep is disrupted by frequent awakenings and getting worse due to anxiety and snoring. He feels tired all the time, has some joint stiffness and night sweats; all other systems were negative. He is going through a divorce which is causing him anxiety and had a hernia repair two month ago. Doctor performs a comprehensive exam and orders labs and a sleep study test. Prescription was given to help with the anxiety. What CPT® code should be reported?

A 55-year-old established patient is coming in for a pre-op visit; he is getting a liver transplant due to cirrhosis. The physician performs an expanded problem focused history, detailed examination, and moderate MDM. Patient agrees with his physician’s recommendations and the transplantation will take place as scheduled. After the evaluation, the patient expresses a number of concerns and questions for the prospective liver transplant. Physician spends an additional 30 minutes, excluding the time spent in doing the E/M service, in counseling and answering questions regarding the surgery and discussing possible outcomes. What CPT® codes should be reported?

Physician performs a medical review and documentation on an 83-year-old patient still hospitalized for confusion for the last two days. She is alert and oriented x 3 today. Reviewing her labs from yesterday, her BNP was elevated suspecting her confusion is due to congestive heart failure. An echocardiogram is ordered and treatment will be for congestive heart failure. Patient is not safe to return home. What CPT® code should be reported?

A plastic surgeon is called to the ED at the request of the emergency department physician to evaluate a patient that arrived with multiple facial fractures after being in an automobile accident for her opinion on the need for reconstructive surgery. The plastic surgeon arrives at the ED, obtains a history of present illness including an extended history of present illness; a system review, including constitutional, musculoskeletal, integumentary, neurologic, and EENMT; and the patient’s social history and past medical history. The plastic surgeon then performs a physical exam including respiratory, cardiovascular, and an extended examination of the skin and bony structures of the patient’s face. The plastic surgeon performs moderate medical decision making, including deciding the patient needs major surgery to repair the injuries. The plastic surgeon schedules the patient for surgery the next day and documents her full note with findings in the ED chart. Code for the plastic surgeon.

At the request of the mother’s obstetrician, the physician was called to attend the birth of an infant being delivered at 29 weeks gestation. During delivery, the neonate was pale and bradycardic. Suctioning and bag ventilation on this 1000 gram neonate was performed with 100 percent oxygen. Brachycardia worsened; endotracheal intubation was performed and insertion of an umbilical line for fluid resuscitation. Later this critically ill neonate was moved from the delivery room and admitted to the NICU with severe respiratory distress and continued hypotension. What are the appropriate procedure codes?

38-year-old female initial visit, just moved from out of state, has neck and back pain for the last year and is getting worse. Pain is exacerbated when she drives, bends, or changes positions, and moderately alleviated with ibuprofen. Positive for aches and weakness in her muscles and tingling and numbness of the arms and hands, as well as headaches. All other systems are reviewed and are negative. She has had a partial hysterectomy and is divorced. Her mother has a history of breast cancer. The physician performs an exam on the following systems: constitutional, eyes, ENT, respiratory, cardiovascular, gastrointestinal, musculoskeletal, and neurologic. X-rays of the cervical and lumbar spine were taken. Will be sending her to get a MRI and to start physical therapy. Prescription was given for muscle relaxer. Select the appropriate CPT® code for this visit?

Mr.Andrews, a 34-year-old male, visits Dr. Parker’s office at the request of Dr.Smith for a neurological consultation. He presents with complaints of weakness, numbness and pain in his left hand and arm. Dr.Parker examines the patient and sends his recommendation and a written report back to Dr. Smith for the care of the patient. Which category or subcategory of evaluation and management codes would you select from for the visit to Dr. Parker?

A mother takes her 2-year-old back to Dr.Denton for an annual well child exam. The patient has a comprehensive check-up and vaccinations are brought up to date. Which category or subcategory of evaluation and management codes would you select from for the well child exam?

John, a 16-year-old male, is admitted by the emergency department physician for observation after an ATC accident. The patient was discharged from observation by another provider the next day. What category or subcategory of evaluation and management codes would you select from for the emergency department physician?

Dr.Hedrick, a neurosurgeon, was asked to assist in a surgery to remove cancer from the spinal cord. He was a co-surgeon working with a orthopaedic surgeon. Dr. Hedrick followed up with the patient during his rounds at the hospital the next day. What category or subcategory of evaluation and management services would Dr.Hedrick’s follow-up visit be reported from?

During a soccer game, Ashley, a 26-year-old female, heard a popping sound in her knee. Her knee has been unstable since the incident and she decided to consult an orthopaedist. She visits Dr.Howard, an orthopaedist she has not been before, to evaluate her knee pain. Dr.Howard’s diagnosis is a torn ACL. What category or subcategory of evaluation and management code would you select for the visit to Dr.Howard?

Patient presents to the clinic today for a follow-up of his hospitalization for pneumonia. He was placed back on Singulair and has been improving with his breathing since then. He has no complaints today. What is the level of history?

The patient presents to the clinic today for an asthma exacerbation. She has been having a cough and difficulty breathing that has been getting worse for the last two to three days. She currently uses inhalers, but could not find any of her inhalers for this past week. She denies any fever or chills. Has a productive cough today. What is the level of history?

History of present illness: This is a 73-year-old man who is a veterinarian. He is seen here for the first time today. He has a history of squamous cell carcinoma on the left arm and basal cell carcinoma on the right forehead near the temple both in January 2007. He says he has had a lesion on his forehead near the temple both in January 2007. He says he has had a lesion on his forehead for approximately one year. He is concerned about what it is. He thinks it may be another skin cancer. He is also concerned about a lesion just lateral to his right eye, he is concerned this may be a skin cancer, too. It has been present for quite a while as well. He would also like a full skin check today. He uses a hat for sun protection. He has lived in California and has had significant sun exposure in the past. Review of systems: Otherwise well, no other skin complaints Past Medical History: Coronary artery disease status post bypass surgery, history of squamous and basal cell carcinoma as noted above, hay fever, and hyperlipidemia. He has had lipomas removed. Medications: Tylenol, tramadol, thyroxin, fish oil, flax seed oil, simvastatin, Zyrtec, 5 percent saline in eyes Allergies: No known drug allergies Family History: No family skin history of skin cancer or other skin problems Social History: Patient is a veterinarian. He recently moved to the Rochester area from Pennsylvania. He is married. What is the level of history?

Established patient Chief complaint: Fever Present Illness: The patient is a 2-year 3-month-old female with less than one day of a high fever with decreased appetite. There has been no vomiting or diarrhea. Parents are unaware of any cough. Tylenol has been given which reduced the fever. Past Medical History: Otherwise negative Current Medications: Tyleno 160 mg.q.4 h, per infant Tylenol drops Allergies: None Immunizations: Up-to-date Review of Systems: As per HPI. Rest of review of systems reviewed and negative Personal, Family, Social History: The patient is not exposed to secondhand cigarette smoke What is the level of history?

Hospital Admission The patient is a 47-year-old white male who presented to the emergency room after the four-wheeler he was operating struck a ditch and rapidly came to a halt. This threw him against the windshield where he struck the mid part of his face and lower lip. This resulted in lip and chin lacerations. He was brought to the emergency room where he was evaluated by Dr. Jones and a CT scan suggested a hyper dense abnormality within the brain. A bleed could not be ruled out. This being the case, admission was recommended. His past history include previous tonsillectomy, previous hospital admission for a syncopal episode associated with pain in the groin area, and hypercholesterolemia. He has no known allergies. His current medications are Zocor and Accutane. He is a non-smoker, moderate drinker of alcohol. The review of systems is negative for nausea, vomiting, blurred vision, or headache.

Physical Exam: General: His physical exam shows an intubated male. He is at times somewhat combative. There is a brace on the right shoulder. Skin: His skin is warm and dry. No rashes, ulcers or lesions. Lungs: The lungs are diminished breath sounds, though no crackles are noted. Cardiac: Cardiac exam is tachycardic, no distinct murmurs appreciated. Extremities show no significant edema. Abdomen: Abdominal exam is soft. No masses or tenderness. No hepatosplenomagaly. Extremities: No clubbing or cyanosis. Bilateral lower. No misalignment or tenderness. Based in the 1995 Documentation Guidelines. What is the level of exam?

Physical Exam: General appearance: Healthy appearing individual in no distress Abdomen: Soft, non tender, without masses. No CVA tenderness Female Exam: Vulva/Labia Majora: No erythema, ulcerations, swelling, or lesions seen Bartholin Glands: No cysts, abscesses, unduration, discharge, masses, or inflammation noted. Skene’s: No cysts, abscesses, induration, discharge, masses or inflammation noted Clitoris/Labia Minora: Clitoris normal. No atrophy, adhesions, erythema, or vesicles noted. Labia unremarkable. Urethral Meatus: Meatus appears normal in size and location. No masses, lesions or prolapsed. Urethra: No masses, tenderness or scarring Bladder: Without fullness, masses or tenderness Vagina: Mucosa clear without lesions. Pelvis support normal. No discharge Cervix: The cervix is clear, firm and closed. No visible lesions. No abnormal discharge. Uterus: Uterus non-tender and of normal size, shape and consisitency. Position and mobility are normal Adnexa / Parameteria: No masses or tenderness noted Based on the 1995 Documentation Guidelines, what is the level of exam?

Physica Exam: General Constitutional: No apparent distress. Well nourished and well developed. Ears: TM’s gray. Landmarks normal. Positive light reflex Nose/Throat: Nose and throat clear; palate intact; no lesions Lymphatic: No palapable cervical, supraclavicular, or axillary adenopathy Respiratory: Normal to inspection. Lungs clear to auscultation Cardiovascular: RRR without murmurs Abdomen: Non-distended, non-tender. Soft, no organomegaly, no masses Integumentary: No unusual rashes or lesions Musculoskeletal: Good strength, no deformities. Full ROM, all extremities Extremities: Extremities appear normal What is the level of exam?

Physical Exam: General: Alert, smiling child HEENT: There is a clear rhinorrhea. Phaynx is without inflammation Neck: Supple Chest: Lungs are clear without wheeze or rhonchi Abdomen: Soft, nontender What is the level of exam?

Physical Exam: Constitutional: Vital signs: 161 Resp: 30 Temp: 102.4. Oxygen saturation 90 percent General Appearance: The patient reveals profound mental retardation. Tracheostomy is in place. Eyes: Conjunctiva are slightly anemic ENT: Oral mucosa is dry Neck: The neck is supple and the trachea is midline. Range of motion is normal. There are no masses, crepitus or tenderness of the neck. The thyroid gland has no appreciable goiter Respiratory: The lungs reveal transmitted upper airway signs and bilateral rales, wheezes, and rhonchi Cardiovascular: The chestwall is normal in appearance. Regular rate and rhythm. No murmurs, rubs, or gallops are noted. There is no significant edema to the lower extremities. Gastrontestinal: The abdomen is soft and nondistended. There is no tenderness, rebound, or guarding noted. There are no masses. No organomegaly is appreciated. Skin: The skin is pale and slightly diaphoretic Neurologic: Cranial nerves appear intact. The patient moves all four extremities symmetrically. No lateralizing signs are noted. Gross sensation is intact to all extremities Lymphatic: There are no palpable pathologic lymph nodes in the neck or axilla Musculoskeletal: Gait and station are normal. Strength and tone to the upper and lower extremities are normal for age with no evidence of atrophy. There is no cyanosis, clubbing, or edema to the digits. What is the level of exam?

Office visit: Here for six mo, check up HPI: Follow-up evaluation of DM and hypertension. She is under a lot of stress. No other new problems or complaints A/P DM: essential hypertension Plan is to continue the same. Return to office in six months for follow up What is the level of Medical Decision Making?

ER visit: Data: BUN 74, creatinine 8.8, K 4.9, Troponin 0.01. I reviewed the EKG which shows some LVH but no ST changes. I also reviewed the CXR, which showed moderate pulmonary vascular congestion, but no infiltrate. Impression: New problem of pulmonary edema due to hypervolemia. No evidence of acute MI or unstable angina. The patient also has ESRD, which is stable, and poorly controlled HTN, which is most likely due to hypervolemia. Plan: I spoke with the dialysis unit. We can get him in for an early treatment this afternoon as opposed to having to wait for his usual shift tomorrow. For that reason, it is okay to discharge him from the ER to go directly to the unit. What is the level of Medical decision making?

Impression: Right recurrent gynecomastia Plan: The patient had a right breast ultrasound on November 17, and it showed a hypoechoic area measuring 1.7 x 0.7 x 1.2 cm in the 11’o clock position of the right breast. There was no Doppler flow, and the transmission suggested that this was a cystic lesion. Follow-up in a month was suggested at that time. Because of this ultrasound and because this is symptomatic, I have recommended a simple mastectomy under general anesthesia. The patient is in agreement. I filled out the prison forms requesting permission, and I described to the patient. What is the level of Medical Decision Making?

ubsequent Hospital Visit: Labs: BUN 56, creatinine 2.1, K 5.2, HGB 12 Impression: 1. Severe exacerbation of CHF 2. Poorly controlled HTN 3. Worsening ARF due to cardio-renal syndrome Plan: 1. Increase BUMEX to 2 mg IV Q6 2. Give 500 mg IV DIURIL times one 3. Re-check usual labs in a.m Total time: 20 minutes What is the level of Medical Decision Making?

Established Patient: Chief Complaint: Gallstones and reflux History of Present Illness: This is a 61-year-old woman who comes back to see me today with a two-year history of severe ‘gallbladder’ attacks. Also of note, she has had ongoing reflux problems for many years. Within the last few months her reflux has worsened. Assessment/Plan: This is 61-year-old woman with likely symptomatic cholelithiasis and reflux. Her number one concern right now is the ‘gallbladder attacks’. This sound like symptomatic cholelithiasis. As a result, we recommended for her to have laparoscopic cholecystectomy with intraoperative cholangiogram. The risks and benefits were explained to the patient who understood and agrees for us to proceed. With regard to her reflux, it is partially controlled by her medication. She also is overweight and might have symptom with improvement after weight loss. She is also very hesistant to proceed with the Nissan fundoplication because her husband had the surgery done before and had some problems with vomiting afterwards. She does have objective evidence of reflux as well and is a good candidate for surgery. However, we will let her decide whether she wants to proceed with surgery or not. What is the level of Medical Decision Making?

An established patient is seen in clinic for allergic rhinitis. A problem focused history, expanded problem focused exam, and a low level of medical decision making were performed. What E/M code would be reported for the visit?

A patient is admitted to the hospital for a lung transplant. The admitting physician performs a comprehensive history, a comprehensive exam, and a high level of medical decision making. What CPT code should be reported?

A new patient is seen in the pediatric office for ear pain. The patient has had pain for four days and it keeps her awake at night. She has had a slight fever (99). She ahs not been swimming or actively in water for the past couple of months. She denies any cough, nasal congestion, or stuffiness, or loss of weight. The provider does a limited exam on the ears, nose, throat, and neck. The patient is determined to have otitis media. Amoxicillin is prescribed. What E/M code would be reported for the visit?

Mrs. Standerfer’s family physician visits her in the nursing home after a spell of dizziness and confusion reported by the staff at the nursing home. She sat down after lunch and stated she was dizzy. She slept for two hours after the spell. She states she is doing much better now. She has a known history of electrolyte imbalance and is on fluid restriction a the nursing home. She has not experienced any chest pain, Dyspnea, unexplained weight changes, or intolerance to heat or cold. No complaints of head or neck pain. During the exam, the physican takes her BP both supine and standing, and notes her pulse and fever. A detailed exam of the eyses, ears, nose and throat is performed along with a detailed neurological exam. The physician orders blood work to determine if her electrolytes are out of balance again. What E/M code would be reported for this visit?

A 45-year-old patient is seeing the neurologist, Dr.Williams, at the request of his family physician to evaluate complaints of weakness, numbness and pain in his left hand and arm. The pain started last year after rocks fell on him while mining. He still has significant, sharp, burning wrist pain and reports the problems are continuing to get worse. He is limited in his job as a machinist for a mining company due to the pain and numbness. He has no swelling in his hand, no neck pain, or radiating pain. His past medical history is negative for significant diseases. He has had carpal tunnel surgery. He had a family history of hypertension, heart disease, and stroke. He is married with children and smokes one pack of cigarettes/day. A detailed exam is performed of the mental status, cranial nerves, motor nerves, DTRs, sensory nerves, and head and neck. After performing an EMG and Nerve Conduction Study, Dr. Williams determined the patient has left ulnar neuropathy at the cubital tunnel rgion, as well as an ongoing carpal tunnel syndrome. Repeat carpal tunnel surgery is recommended, along with a possible cubital tunnel surgical procedure. If the patient does not have surgery, he risks permanent nerve damage. A report is sent back to the physician requesting the consult. What E/M consultation code would be reported for this visit?