A 36-year-old presents to the Emergency Department with sudden onset of lower right quadrant pain with nausea, severe vomiting, and a high fever of 102 degrees. An appropriate history and exam are documented. Exam of the abdomen is very tender and patient screams when the abdomen is touched. The ED physician orders a CT scan and orders CBC and CRP lab tests. The tests show that the patient has a ruptured appendix. ED physician consults with a surgeon and discusses the tests. The decision is made for emergency surgery to remove the appendix. What E/M EM level is reported?

Day 1 - A 67-year-old is placed in the observation unit due to having COPD with asthma exacerbation. The physician performs an appropriate history and exam. The medical decision making is of high complexity. Day 2. - The physician was able to stabilize the patient's respiratory status with a breathing treatment but wants to keep him in observation status overnight to see if he remains stable or deteriorates. On the second day in the observation unit, pulse ox was taken and is 89 percent. The physician orders oxygen and requires the patient to spend another day in the observation unit to continue monitoring the patient's oxygen levels. Total time spent with the patient is 30 minutes. Day 3 - On the third day, the physician retakes the pulse ox which now shows 95 percent. The patient is breathing comfortably and appears to be stable. The vitals are within normal range. The physician discharges patient. Total time for discharge is 15 minutes

Dr. W is going to take over the care of a 35-year-old male that was referred to him from Dr. X. The patient has been having severe abdominal pains with nausea and vomiting. A comprehensive history documented. A detailed examination of 6 organ systems is performed along with a moderate medical decision making in which CT and abdominal films were reviewed showing a small bowel obstruction that is not completely defined. Dr. W orders another CT scan in the morning. What E/M category is reported for Dr. W?

A physician is performing a follow-up on his patient in a nursing facility who was discharged two days ago from the hospital for malignant hypertension. Appropriate history and exam are performed. MRA is ordered to rule out renal artery stenosis. The patient is given a prescription for a Clonidine patch in addition to his current regimen 1 mg once a week. What is the MDM level for Risk of Complications and/or Morbidity or Mortality of Patient Management?

Patient is coming to see his primary care physician for a scheduled procedure, aspiration of fluid from his shoulder. Only a brief exam of the shoulder was performed, followed by the aspiration. How is this reported?

A neonatal physician is called to attend a delivery for a patient who is having a premature birth and has had many complications affecting the fetus. When the baby is born, he is not breathing and is blue. The neonatal physician initiated positive pressure ventilation and chest compressions. Once the new born was stabilized, he was admitted to the neonatal intensive care unit in critical condition. In the unit he was placed on a monitor and a ventilator. Lab work was ordered along with starting an IV. What E/M code(s) should be reported?

A 60-year-old male has been admitted as an inpatient to the hospital for three days due to diverticulitis. The attending physician performs a problem focused examination and reviews her lab and radiology tests. Instructions are given on what type of diet needs to be followed to avoid another episode of inflammation. A prescription is given and a referral to see a Gl consult. Discharge papers are signed for him to go home. The total time spent with the patient is 30 minutes. What E/M service is reported?

A 2-month-old is coming in for the first time to have a routine well baby visit. The mother states the baby excessively cries during the night hours. The paediatrician performs the examination, and everything is normal. Mother agrees to have the vaccination injections done at this visit. The paediatrician tells the mom that the baby is colicky Counselling was given to the mother to help with the colic. What E/M service and ICD-10-CM codes are reported for this visit?

A 45-year-old patient is coming in for a follow-up examination with her primary care physician. She was just discharged from the hospital two days ago for having uncontrolled type 2 diabetes. The physician performs a medically appropriate history and examination. The physician spends a total time of 75 minutes with the patient including counselling the patient on making changes in her lifestyle to deal better with her diabetes. Goals are set for an exercise routine and a diet plan. Insulin administration, hypoglycemic reactions as well as the symptoms of hyperglycemia are also discussed. What E/M coding is reported?

A 20-year-old who is 22-weeks pregnant was admitted to the hospital by her obstetrician in the morning for having vaginal bleeding. An appropriate history and exam are performed. Later in the afternoon the patient's obstetrician reviewed patient's lab work, ultrasound, and the baby's heart rhythm is back to normal. The patient was no longer bleeding and was given orders for bed rest. The obstetrician discharged her that afternoon and asked her to follow-up in the office in the next two days. The obstetrician the E/M service from which E/M category?

A patient is admitted in observation care for pain control due to acute back pain after a lumbar fusion performed a week ago. The emergency physician documented an appropriate history and exam. CT scan of the spine is ordered. The patient was given Percocet orally and had periodic assessment to monitor her pain. Neurosurgery was called for a consultation and will make the decision whether to admit the patient. What E/M service is reported for the emergency physician?

A primary care physician requested Dr. X's opinion on a patient who has difficulty grasping objects with her left hand due to decreased range of motion of the ring finger. Dr. X performs an appropriate history and exam. Dr. X reviewed the hand X-ray sent by the primary physician. The X-ray revealed osteoarthritis at the PIP joints of both the left and right ring fingers. Dr. X recommended the patient follow up with her primary care physician. He will provide a letter to the primary care physician to start taking over the counter Aleve. The patient expressed an understanding and will return to her primary care physician. What E/M service does Dr. X report?

A 10-day-old is admitted in the NICU with critical respiratory distress. An arterial blood gas is ordered, and the physician's interpretation is respiratory acidosis. The physician performs endotracheal intubation and places the baby on a ventilator. What is the CPT® coding?

Primary Care Provider: Dr. Atkins, Internal Medicine Physician Service Provided and Documented by: Dr. Collins, Internal Medicine Physician (substituting for Dr. Atkins [not part of Dr. Atkins medical group] while he is on leave for a medical conference) Patient: T. Myers DOS: 06/202X Patient is a 56-year-old male who an established patient of Dr. Collins is. He is seen today for continuing swelling of the legs. This is not a new problem; however, the episodes of swelling are increasing and every day in the afternoon. Dr. Collins' documentation shows a medically appropriate history and exam. An ultrasound of both legs and EKG are ordered to rule out blockages in his leg arteries. What CPT® code is reported?

Dr. Y sees his patient in the hospital for worsening abdominal pain. An X-ray of the gallbladder revealed cholelithiasis with cholecystitis. Dr. Y orders a Morphine IV (parenteral controlled substance) for pain control, antibiotics, and will perform a major surgery of removing the gallbladder with no patient risk factors. What MDM level is for the Risk of Complications and/or Morbidity of Patient Management?

A 41-year-old patient is seen for the first time by the physician for a risk reduction mastectomy for her BRCA-1 positive status. The physician performs medically appropriate history and examination. The physician spends a total time of 65 minutes discussing breast reconstruction options, tissue expander options and the benefits of quitting smoking due to the risk of infections and/or complications of surgery. How is this visit reported?

A 58-year-old who has been seeing her obstetrician for two years, returns for yearly well woman examination. She has no complaints. An expanded problem focused exam is performed. Pelvic exam revealed cervical polyps abd a pap smear was performed. Her atrophic vaginitis is responding well to the estrogen cream. A D&C hysteroscopy was discussed for further examination of the cervix and removal of the present polyps discussing the risk of surgery. She is scheduled for a mammogram, bone density, and ultrasound. Which E/M service is reported for this visit?

Dr. X is called to the ICU for a patient in respiratory failure. The patient is found to have bilateral pleural effusions and a distended abdomen with shifting dullness to percussion. The patient is intubated and ventilated by Dr. X. The physician reviews the last assessment in the chart to adjust the infusion of medication level. Orders of an ABG to be performed in the next hour. Total care time documented is 104 minutes which does not include the time performing the intubation.

An 87-year-old was admitted last night to the hospital. Her primary care physician requested a cardiologist's opinion since she was admitted for malignant hypertension and is complaining of weakness in her legs with decreased sensation and pain in her feet. The cardiologist performed an appropriate history and exam. The cardiologist orders an EKG and provides the following interpretation: Test Status: normal Rhythm: normal sinus rhythm AV Blocks: none IV Conduction: normal ST Response; normal The cardiologist also bills for the EKG. How is the EKG counted in the MDM level for Amount and/or Complexity of Data to Be Reviewed and analysed?

A 15-year-old girl is scheduled for her yearly physical with a new paediatrician. At the time of the visit, the patient complains of nasal congestion, headache, and watery eyes for the past three days. The provider performs the physical. He also performs a history and exam for the symptoms the patient complained about. The patient is having seasonal allergies and treats the patient with low medical decision making. What CPT® coding is reported for this visit?

A 28-day-old male child is brought into the emergency room in respiratory arrest with suspected SIDS. The emergency room physician performs critical care for 45 minutes. In addition to the critical care time, CPR, placement of a central venous line, and emergency endotracheal intubation are performed. What procedure codes are reported for this encounter?

Emily, 23-months-old, has severe diarrhea and vomiting according to her mom. She is extremely dehydrated. She is brought to the outpatient clinic to see her pediatrician. The mom provides the history. The patient’s pediatrician performs a medically appropriate history and examination. The physician orders labs to be performed in the office including carbon dioxide, chloride, potassium, and sodium. The nurse performs venipuncture to obtain the blood sample. The physician diagnoses the patient with dehydration and instructs the mother to increase fluid intake to hydrate the baby. What procedure and diagnosis codes are reported for this encounter?

An established 45-year-old woman is seen today at her doctor’s office. She is complaining of being dizzy and feels like the room is spinning. She has had palpitations on and off for the past 12 months. She reports chest tightness and dyspnea but denies nausea, edema, or arm pain. She drinks two cups of coffee per day. Her sister has Wolfe Parkinson-White (WPW) syndrome. A medically appropriate history and exam are performed. An EKG is ordered. The provider does not document a final diagnosis. What CPT® code is reported for this visit?

A 33-year-old white male was admitted to the hospital 12/17/16 from the ER, following a motor vehicle accident, to have a splenectomy done. The patient is being discharged from the hospital on 12/20/16. During his hospitalization, he was experiencing pain and shortness of breath, but with an antibiotic regimen of Levaquin, he improved. The physician performed final examination and reviewed chest X-ray that revealed possible infiltrates and a CT of the abdomen that ruled out any abscess. He was given a prescription of Zosyn. The patient was told to follow up care with PCP or return back to the hospital for any pain or bleeding. The physician spent 20 minutes. What CPT® code is reported for the 12/20 visit?

Established Patient' Chief Complaint: Losing concentration Problem List: Anxiety and depression Clinical Service: A 30-year-old with complaints inability to focus and lost concentration. She has a history of anxiety and depression, but lately has been unable to focus on one project at work. After a moderate level MDM evaluation and management encounter, the psychiatrist recommended that patient undergoes a Computerised Neurocognitive Assessment called CNS vital signs. The test was administered by the medical assistant, who was managed by the physician. The test took an additional one hour beyond the office visit. Final diagnosis: ADHD What are the CPT codes reported?

History: A 24-year-old female patient who attempted suicide by sleeping pill ingestion was admitted into observation before being transported to the mental health facility. Currently in the facility doing rounds, the PCP visited the patient in the observation unit. Concerned that the patient may be experiencing residual neurological effects resulting from the ingestion, at bedside, the PCPcarried out a medically appropriate history and exam. He reviewed the following in the patient's chart: ECG, EKG, Toxicology report Final diagnostic statement: Suicide attempt, Chronic nervous twitch (unknown etiology). The decision was made to admit the patient into the hospital for further testing. Prolonged time: One hour beyond the evaluation and management service.

12-Year-Old Female with Seizures A 12-year-old female is brought by her mother for a follow-up of known complex partial seizure disorder on carbamazepine. Pre-Visit: Reviewed prior clinic notes [2 MINS] Visit: Performed medically appropriate history and exam. No recent reported seizures since carbamazepine was initiated. No signs of toxicity on exam. She and family are counseled about her diagnosis of epilepsy, seizure precautions. [20 MINS] Post-Visit: Document encounter (3 MINS)

12-Year-Old Female with Seizures Returns for a three-month follow-up visit and her mother denies witnessing any seizures and the patient denies side-effects. Pre-Visit: Personally reviewed MR images which reported a cortical dysplasia in the left frontal lobe. Her EEG report was read as normal [5 MINS] Visit: The significance of the cortical dysplasia was reviewed, as were images. No symptoms or signs of toxicity on exam. Oxcarbazepine was continued and appropriate surveillance labs were previously obtained and reviewed during the visit [25 MINS] Post-Visit: Document encounter [3 MINS]

12-Year-Old Female with Seizures In the past six months, seizures became refractory to two medications, requiring multiple ED visits in the interim. She underwent a presurgical evaluation. You presented her at a multidisciplinary conference where surgery was recommended. Pre-Visit: You review the consensus recommendations, MR, PET, EEG, and neuropsychology report [7 MINS] Visit: Discussion of surgical recommendations, treatment alternatives, and risk of sudden unexpected death in epilepsy patients with patient and parents. Referred patient to neurosurgery for formal consultation. You maintain oxcarbazepine, but increase clobazam [25 MINS] Post-Visit: Place referral and send prescriptions, document encounter [4 MINS]

Time seen by clinician. 1835 Chief Complaint: Ankle and leg injury History present illness 15-year-old male patient complains of an injury to the leg and foot. The injury occurred shortly prior to arrival. The injury allegedly occurred while playing football at local high school field, another player fell on his leg and foot. Mother states she saw the child when he fell, his leg twisting when the other players fell on him. Patient did not continue playing any more football, mother states he's not walking on his leg at all secondary to pain. No other complaints of pain, injury or illness. Patient's allergies: NKDA Patient's current medications: no routine prescription medications Review of systems: All other systems negative. Social History. Public school, lives with family Family History: Noncontributory visit today Physical Exam, Vital Signs: Afebrile, VSS General, well appearing, well nourished Patient Status. Alert and cooperative Heart: RRR, no MRG Lungs: CTAB Ankle: Right ankle, diffuse tenderness medial and lateral malleolus, minimal swelling laterally, ROM normal flexion, normal plantarflexion , no obvious deformity, skin is intact. Neurovascular status: 2+ pedal pulses, capillary refill less than 2 seconds Achilles tendon non tender, no step off. The foot, knee and hip are without pain or tenderness and with full range of motion Leg: Right, diffuse pain tibia-fibula, no obvious swelling. Patient has poison ivy bilateral lower legs, no infection. Mother states he has medication for his poison ivy. Intervention Xray: Right tibia fibula and foot negative for acute bony injury Immobilization was achieved by the application of OCL stirrup short leg splint applied by ortho tech Immobilization device was then check to assure good neurovascular flow and effectiveness of positioning before the patient was discharged Crutches dispensed. Crutch walking safely with good use of crutches Diagnosis: Ankle injury from trauma Acute sprain right ankle Contusion right leg Disposition: The patient was discharged 1855. Discussion regarding radiology to review x-rays and in the event of a discrepancy we will notify patient/family. Prescriptions: Prescription for Vicodin Discussion regarding ice, elevation, rest leg and ankle, nonweightbearing until follow up Follow up: Instructions given to follow up with MD or orthopedics in 4- 5days. May return to ER or orthopedics sooner for worsening symptoms Treatment plan discussed with patient/family who are in agreement. What is the type of MDM?