SlideShare a Scribd company logo
1 of 31
CHAPTER 15 r Evaiuation and Management (E/M) Services
,/fA, four types of medical decision making, in order of
complexity from most to
List the fi
least risk
,d--A-
A-
,lr,
-lr-
Inpatient time spent at the bedside or nursing station during or
after
the visit is what kind of time?
21. Thepatient's will reflect the
. nrm-ber of systems examined by a brief statement of the
findings.
/ZZ. I discussion with a patient andlor family concerning one or
more of
the following areas: diagnostic results, impressions and/or
recommended diagnostic studies; prognosis; risks and benefits
of
treatment; instruciions for treatment; importance of compliance
with
treatment; risk factor reduction; and patient and family
education is
23. The history is the
physician.
information the Patient tells the
Ol4r11bcrd .rasvl-crs are located in Appendix B, while the full
answer key ls only available in the TEACE
Iffir Ecsorrrces on Erolve.
-4
,r{
/n.
,{
13. Complexity of medical decision making is based on three
ve types of presenting problems from the most risk and least
recovery to
and most recovery:
19. Counseling and coordination of care are what kind of factors
in most
cases?
U/O. ,r*"that is used as a guide for outpatient services is what
kind of time?
Cop].right @ 2015 by Saunders, an impdnt of Elsevier Inc' A1I
rights reserved'
CHAI{ER 15 r Evaluation and Management (E/l[l Sersices
6n. ,n"re is no distinction made between the new and
established patients
in this service department of a hospital:
25. Those services rendered by a physician whose opinion or
advice is
requested by another physician or agency in the evaluation
and/or
treatment of a patient is a(n) whereas the
physician who has primary responsibility for the patient in the
hospital
is called
r'26. Whencritically ill patients in medical emergencies require
the constant
attendance of the physician (e.g., cardiac arrest, shock,
bleeding, and
respiratory failure) to stabilize them, what kind of care is
needed?
27. When care is provided
same patient by more
conditions, the care is
for similar services
than one physician
(e.g., hospital visits) to the
on the same day for different
,6. *nuris the name for the assumption of the total or speciflc
care of a
patient from one physician to another that does not constitute a
consultation?
29. An inventory of body systems obtained
signs and/or symptoms that the patient
."{o. ,tthe physician who is standing by does so for 25 minutes,
can he ot
she round the time up to 30 minutes for reporting purposes?
through questioning to identifY
may be experiencing is a(n)
of
Odd-numbered answers are located in Appendlx B, while the
full answer key is only avaitrablc ir ft TEI'€E
Instructor Resources on Evolve.
Copyright @ 2015 by Saunders, an imprint of Elsevier Inc. A11
rights reserved.
CIL{PTER 15 r fyil*5on irnd Management (E/}vf) Services
PRACTICAT
Office or Other Outpatlent Services and Hospltal lnpatient
Service
With the use of the CPT and ICD-10-CM/ICD-9-CM manuals,
camplete the
following:
3. Analyze this case in which the patient record states: 40-year-
old male
patient (new) is evaluated for contusion of a finger. The history
and
examination were problem focused.
a. Diagnosis and management options for contusion of finger.
(Options
can be minimal, limited, multiple, or extensive.) Diagnosis and
management options:
Data to review to provide service. (Data can be minimal/none,
limited, moderate, or extensive.) Only data available are current
information obtained during the visit. Data:
b. Risks if left untreated. (Risk can be minimal,
Risks:
low, moderate, or high.)
c. All three of the elements have been met to qualify this patient
for
what level of decision making complexity?
d. The patient record indicates that a problem focused history
and
examination were done. When this is combined with the level of
decision-making complexity you arrived at for this patient, what
is
for 48 hours is discharged
from the hospital. The patient was being observed after a motor
vehicle
accident for subdural hematoma, subsequently ruled out. Code
onty the
discharge services and diagnosis.
CPT Code:
ICD-1O-CM Codes:
(ICD-9-CM Codes:
33. Initial observation of a patient was for upper abdominal
pain, dizziness,
and anemia. A comprehensive history and examination was
performed.
Moderate complexity decision making was conducted to admit
the
patient to observation to treat and rule out causes of the
patient,s
anemia.
CPT Code:
(nrnbcrcd arlsrYers are located in Appendix B, while the full
answer key is only available ln the TEACH
hltrrcfa fcrm,ccs oa Evolve.
the correct CPT code for the case? Code:
{32. A patient who was on observation status
Copr.right @ 2015 by Saunders, an imprint of Elsevier Inc. All
rights reserved.
CHAPTER 15 r Evaluation a.n; 0nmw:3,
/74. A 16-year-old female is being admitted by her familr
rorffir:u ,
with a 2-week history of fatigue and fever. It has b€en SW,'l*
getting worse. She is suffering from dehydration. The F.xr.: -
performs a comprehensive history to look for explanab;n: r"r
fatigue, including recent activity level and recent sleep [:.a:m:
detailed examination is performed and she is diagnosed -w:
mononucleosis and admitted for treatment.
CPT Code:
ICD-10-CM Codes:
(lCD-9-CM Codes:
35. A 56-year-old male with an established history of ASHD of
natire
arteries and past stent placement is admitted through the
emerger::*,
room with acute onset of chest pain. An EKG was performed
and
troponin levels taken. Both showed evidence of the patient
having a::
acute inferior wall myocardial infarction. The cardiologist
performs a
comprehensive history, with the chief complaint, 4 from the
histon c:
present illness (HPI), a complete review of systems (ROS), and
past,
family, and social history (PFSH). The history includes the
information
that the pain started a week ago but last night worsened. Also
on a scale
of 1 to 10, he rated the pain an 8. It was also discovered that the
patient has not been attending regular appointments in the clinic
setting. A comprehensive examination was performed along
with high-
complexity medical decision making (MDM), including
management of
the patient's acute MI and reviewing data of the medical history
of the
patient. He was taken immediately to the cardiac catheterization
lab to
look for the source for the patient's ML
CPT Code:
ICD-1O-CM Codes:
(ICD-9-CM Codes:
/36. Th"patient is a 34-year-old established patient seen in the
clinic by her
dermatologist. She is followed for extensive psoriasis involving
her scalp,
trunk, and arms. It has now worsened and spread to her palms,
and she
is now also complaining of ioint pain. The spread to her hands
has made
it difficult to do many of her day-to-day tasks. A detailed
history and
examination are performed. The examination includes
inspection of the
affected areas in addition to bending and rotation of joints. A
long
discussion took place regarding a change in her medications to
try to
gain better control of her psoriasis and slow down the systemic
progression. Topical and systemic treatment was decided on.
CPT Code:
ICD-10-CM Codes:
(ICD-9-CM Codes:
Odd'numbered answers are located in Appendix B, while the full
answer key is only available in the TE-.,CH
Instructor Resources on Evolve.
Copyright @ 2015 by Saunders, an imprint of Elsevier inc. Al1
rights reserr.,ed.
:":--rJll} :: I
3;- -{ l!-yearold boy with bacterial pneumonia is ho5pitalized
and has had
5 days of antibiotic therapy. Today the child developed a fever
of 101' F
rtith a mild rash on his tofso. In a subsequent hospital visit, the
attending physician performed a problem focused history and
examination. The MDM complexity was low.
CPT Code:
ICD-1O-CM Code:
(ICD-9-CM Code:
*46. fne patient is a 52-year-old male from out of state visiting
his daughter.
He left his medications for his benign hypertension at home and
is now
here in the clinic in need of a prescription. A problem focused
history
and examination is performed and a prescription is given to the
patient.
CPT Code:
ICD-10-CM Code:
(ICD-9-CM Code:
Consultation Services
39. A 47-year-old female was sent by her family practice
physician for an
office consultation with a gynecologist. The patient has been
suffering
with moderate pelvic pain, a heavy sensation in her lower
pelvis, and
marked discomfort during sexual intercourse. In a detailed
history, the
gynecologist noted the location, severity, and duration of her
pelvic
pain and related symptoms. In the review of systems, the patient
had
positive findings related to her gastrointestinal, genitourinary,
and
endocrine body systems. The physician noted that her medical
history
was noncontributory to the present problem. The detailed
physical
examination centered on her gastrointestinal and genitourinary
systems, with a complete pelvic examination. The physician
ordered
laboratory tests and a pelvic ultrasound to determine uterine
fibroids,
endometritis, or other internal gynecological pathology. The
MDM
complexity was moderate.
CPT Code:
ICD-10-CM Codes:
(ICD-9-CM Codes:
lO. A38-year-old female has severe low back pain due to a
trauma injury
she experienced as a factory worker 4 years ago. The chronic
pain has
become almost unbearable, and her internal medicine physician
cannot
go any further with her treatment. An initial outpatient
consultation is
requested and the patient is sent to see the pain management
specialist
for suggestions to control the chronic pain. A comprehensive
history is
taken, including all of the pertinent information regarding her
iniury.
During the comprehensive examination the patient's gait and
Odd-numbered answers are located in Appendlx B, while the
full answer key is only avallable in the TEACH
Instructor Resources on Evolve.
Coplaight @ 2015 by Saunders, an imprint of Elsevier Inc. All
rights reserved.
CHA?TER 15 r Evaluation arld {anagement rBUt Senices
movement were obselved. Moderate-complexit-V decision
maliing is
peformed, including different treatment options' A separate not€
is
di.tut"d to show thirequesting physician what results rt"ere
found
during the visit and the decision on treatment of her pain'
CPT Code:
ICD-10-CM Codes:
(ICD-9-CM Codes:
CPT Code:
CPT Code:
ICD-10-CM Code:
(ICD-9-CM Code:
41. An inpatient urological consultation is performed for a 3}-
yearold
female who recentiy had an elective abortion performed on an
outpatient basis. The woman has been admitted with a high
fever, pelvic
pain, and dysuria. During a detailed history, the urologist notes
in the
irirtory of piesent illness that the patient's symptoms began
abortt 2
days ifter ihe abortion and progressed to the acute phase, which
she is
in at the present time. The lbcation of the pain is in the lower
abdomen
and rated 9 on a scale of 1 to 10. She reports the quality of the
pain to
be sharp and stabbing. In the review of systems, the physician
notes
positive responses in 5 of the L2 body systems investigated. The
urologist notes a negative medical history related to urinary
symptoms
other-than a mild.frtitl. about 10 years ago. The detailed
physical
examination performed by the urologist centels on the
genitourinary
system and gistrointestinil system in significant detail..The
medical
decision making is low. Given the patient's past surgical
procedure and
physical findinfs at the present, the consultant considers the
diagnoses
of pyelonephritis, cystitis, pyelitis, and endometritis'
',)
,d. O46-year-old male is admitted to the hospital with a
progressive
staptrylococcal pneumonia that is not responding to treatment'
A
r"qr.it is made for the infectious disease physician on staff to
render
his opinion for treatment. The patient is seen in initial inpatient
.onrrltation. An expanded problem focused history and
examination
are performed. Aftei looking at the sputum cultures, t{:
PhYsician
decides on the most effective antibiotic for treatment' The
decision
making is straightforward.
43. The initial consulting physician subsequently sees a Ss-
year-old patient
injured at work whei
-he"fell
from a house roof and struck his head- The
patient had a right frontal parietal craniotomy 6 days
previousll'and is
iecovering rapidly. The initial consultation was requested
regarding a
possible d-rug reactlon that produced a rash on the uppel torso.
The-
consultant ricommended a medication change, but after 48 hours
t1.e
patient had no improvement. The physician re-evaluates for
other
possible causes of ifre rash. An expanded problem focused
inten-al
Odd-numbered answers are located in Appendix B, while the
full answer key is only available in th€ IEACE
Instrrrctor Resources on Evolve.
copyright @ 2015 by Saunders, an imprint of Elsevier Inc. A11
rights reserved.
CFLPTER 15 r Evaluation and Management (E/M) Services
history and a physical examination were performed. The MDM
complexity was moderate.
CPT Code:
ICD-10-CM Code:
(ICD-9-CM Code:
/++. l,44-year-old patient, with chronic mastoiditis, was seen in
consultation by the ENT specialist in the office. Her physician
was
inquiring as to the advantages of surgery versus continued
antibiotic
treatment when an acute flare comes on. The ENT specialist
recommends surgery because of the increasing severity with
each acute
flare. She is fearful of the surgery because of the need to go
under
general anesthetic and a fear of permanent hearing loss. The
physician
performs an expanded problem focused history to include the
duration
of this problem and how many acute flares ayear the patient
experiences. An expanded problem focused examination and
straightforward decision making is completed. It is determined
that
with the number of acute flares a year and the increasing
severity of
each case that surgery is recommended. The patient's fears are
laid to
rest and the patient decides to go ahead with the surgery.
CPT Code:
ICD-10-CM Code:
(ICD-9-CM Code:
45. This is a follow-up visit on a Z9-year-old male who is
admitted with the
diagnosis of headlches. The patient is subsequeptly seen
because the
physician needs to follow up on test results that weren't back
yet at the
initial consultation. This wiii help to find a possible cause of
the
headaches and course of treatment. A problem focused history
and
examination and low-complexity decision making is made after
viewing
the CT results. The diagnosis of tension headaches was made
and
treatment options discussed.
CPT Code:
ICD-10-CM Code:
(ICD-9-CM Code:
u/+0. An 83-year-old patient is seen at the local nursing home.
The patient-
suffers from severe COPD. Routine labs were drawn on the
patient by
her primary doctor and her blood sugar came back abnormal.
Fasting
glucose was then taken and was high. The endocrinologist was
asked to
render an opinion on a possible diagnosis of diabetes. A
problem
focused history and examination and straightforward decision
making
were made. Diabetes was diagnosed and treatment started. The
endocrinologist contacted the primary physician and discussed
treatment of the patient. Report services for the endocrinologist
only.
Odd-numbered ansrf,ers are located in Appendix B, whlle the
full answer key is onty available in the TEACII
Instructor Resources on Evolve.
Copyright @ 2015 by Saunders, an impdnt of Elsevier Inc. All
rights reserved.
CHAPIER 15 r Evaluation and Managem€rt rE]{i Strr-x:
CPT Code:
ICD-10-CM Code:
(ICD-9-CM Code:
47. Apatient is sent to a general surgeon by her family
physician for an
oplnion and recommendation for surgical repair of a recurrent
femoral
hernia, right. A brief problem focused history of present illness
and a
problem focused examination of the affected body area and
organ
system are performed in the office. The MDM complexity was
straightforward.
CPT Code:
ICD-IO-CM Code:
(ICD-9-CM Code:
,r/+5. I pulmonologist is asked, by the patient's primary
physician, to see a
14-month-old boy who was admitted to the hospital with
respiratory
distress, cough, and fever. A comprehensive history is taken
from the
. parents because this is an infant. It was determined that the
patient'
does attend a day care facility. The cough and fever have been
present
for approximately 5 days. The infant stalted having trouble
breathing
this morning. The patient is intubated. Pneumonia due to
respiratory
syncytial virus is the definitive diagnosis. A comprehensive
examination
ii peiformed along with moderate decision making. More tests
will
follow. A copy of his dictation will be sent to the primary
physician.
CPT Code:
ICD-10-CM Code:
(ICD-9-CM Code:
49. Office neurosurgery consultation is requested by the
primary physician
fot a 3Z-year-old man on workers' compensation who is unable
to work
because of displacement of intervertebral lumbar disc with
myelopathy.
TWo previous surgical repairs have been unsuccessful in
relieving the
patient's pain. The patient has been unable to return to his
employmint as a bricklayer. He complains of radiating pain
throughout
the buttocks and leg, with numbness throughout the leg and
foot.
Reflexes are minimal to nonexistent. A comprehensive history
and
physical examination are performed. MDM complexity was high
due to
the prior surgeries and continued complaints.
CPT Code:
ICD-10-CM Code:
(ICD-9-CM Code:
Odd-numbered answers are Iocated in Appendix B, while the
full answer key is only available in thc TE{(f,
Instructor Resources on Evolve.
Copyright @ 2015 by Saunders, an imprint of Elsevier Inc. All
rights teserved.
C}L{PTER 1S r Er-aluation and {anagement (E/M) Services
Emergency Department Services, Nursing Facility, Domiciliary
and Home Services
,iO. A patient presents to the emergency department after being
involved in
a motor vehicle accident. The patient was wearing a seat belt.
The
vehicle rolled numerous times. The patient's head struck the
side
window. The patient is unresponsive and is intubated. A history
was
unable to be obtained because of the patient's unresponsiveness.
What
history is available comes from the paramedics and patient's
record. A
comprehensive examination reveals the abdomen to be quite
swollen
with extensive bruising around the lower abdomen caused by
the seat
belt. High-complexity decision making was involved and the
patient
was rushed to the operating room.
CPT Code:
51. A male patient presents to the emergency department with a
wrist
sprain sustained in a softball game when the patient slid into
home,
striking his hand on home plate. The patient is in apparent pain
with a
swollen wrist, which he is unable to flex. An expanded problem
focused
history and physical examination are done. Rad?ographs show a
CoIIes'
fracture of the distal radius. The MDM complexity was low.
CPT Code:
ICD-10-CM Codes:
(ICD-9-CM Codes:
,./SZ. An 88-year-old female's family physician comes to the
nursing facility
to perform the resident's annual assessment. A detailed interval
history
is taken with some information from the patient, but because of
her
limited cognitive abilities, most of the information is gathered
from the
nurses and past records. A comprehensive multisystem physical
examination is performed, which includes extensive body areas
and
related organ systems. The MDM complexity was moderate
because
multiple diagnoses must be considered for this patient, who has
senile
dementia, diabetes, hypertension, hypothyroidism, and recurrent
transient ischemic attacks. The creation of a new treatment plan
is
required because some of the patient's conditions have
worsened.
CPT Code:
ICD-10-CM Codes:
(ICD-9-CM Codes:
Odd-numbered answers are located in Appendix B, while the
full answer key is only avallable ln the TEACH
Instructor Resources on Evolve.
Copyright @ 2015 by Saunders, an impdnt of Elsevier Inc. A11
rights reserved.
CHAPTER 1.5 r f1-n1g31ion ard 1.:-,:. _-..:.: : l.: :=.-
53' This is a home visit on an elderly gentleman,
pre'ioush'i.inrr- -,, r-- lme, who is complaining of edemaln his
iowei extremirics. f ;-r. -iassociated with this. An expanded
problem focused histor:,. a:;
examination are performed and ro* complexity decisior, *uiJ..
_stockings are prescribed.
CPT Code:
/54. subsequent foilow-up care is provided for the B2-year-old
mare nursingfacility patient with Alzheimelr's disease. The
resident has respondedwell to some new medications and
appears to have recovered some ofhis cognitive abilities without
behavioral disturbances. The physicianperforms a problem
focused history and physicar examination on hisnerrrological
problem and orders the current treatments continued. TheMDM
complexity is low.
CPT Code:
ICD-1O-CM Code:
(ICD-9-CM Code:
ICD-1O-CM Codes:
(ICD-9-CM Codes:
55. Subsequent follow-up care is provided for the patient who
was
transferred to a skilled nursing facility from an'acute care
hospital afterpartial recovery from.a stroke-The pitient has
deveroped periods ofextreme dizziness and mental confusion. A
detailed iiterval historv isgathered, and a detailed physical
examination of the
"ff".i;; b.;;
"
systems is performed. Given the possibility that a new stroke
could ha'eoccurred or that other neurological problems have
developed, neworders are written, and the ptrysician plans to
return the next day toevaluate the patient's condition again. The
MDM compiexity is
moderate.
CPT Code:
ICD-10-CM Codes:
(ICD-9-CM Codes:
copyright @ 2015 by Saunders, an imprint of Eisevier Inc. Alr
rights reserr.ed.
_-
--.--------.-------.------.------..------.-._--)
146- the physician provides services to a resident of a rest home
for,:,ulcerative sore on the heel and midfoot. Given the fact that
ih.:-1r-.:r:
is in reasonabry good health and is not diabetic, tne pn.:sic,";' --
....his attention on the right lower extremity during the prcbl.::.
- -.--._:physical examination. The physician knows the resideni
,.r;- 11_performs a brief HpI and ROS during a problem focused
l_:: - - , , _,.resident thinks the sore is from new=shies, and the
p.i.rl.-,-,_ ,. -,-_.
odd-numbered answers are located in Appendix B, while the full
answer kev is onl- a'ailable in the TE f HInstructor Resources
on Evolve.
r=il9[8. 15 r Srpa-,i"o ad ]arnrGffit ,Ef, Sersic.es
with that corclusion. Topical antibiotic cream is ordered, and
the new
shoes are sent to the cobbler to be stretched. The MDM
complexity is
straightforward.
CPT Code:
ICD-IO-CM Code:
flCD-g-CM Code:
57. The physician provides services to a new patient who is in a
custodial
care center. The patient is 43 years o1d and is paraplegic, with
severe
infected stasis ulcers. The physician performs a detailed history
and
examination and prescribes an antibiotic. The MDM was
straightforward.
CPT Code:
Pyolonged Services and Preventive Medicine Services
4g. 'Mestablished patient is seen in the offlce for a new problem
that
requires a comprehensive history and examination. The MDM
complexity is high, and the physician spends 40 minutes with
the
patient. However, the patient has numerous concerns, and the
physician spends an additional hour and 50 minutes in
prolonged
direct patient contact.
CPT Codes:
59. A 44-year-ord asthmatic patient (new) is scheduled for a
routine office
visit for a complaint of severe headaches. The physician
provides a
comprehensive history and examination. The MDM complexity
was
high. Toward the end of the visit, the patient develops severe
breathing
complications, and the physician spends the next hour and 30
minutes
administering treatment.
CPT Codes:
/
,/OO. e 64-year-old man arrives at his appointment with his
family physician
for his annual physical examination. The patient has no new
complaints and all of his medications remain the same. He is
told to
follow up in 1 year or sooner if necessary.
CPT Code:
Services from Throughout the E/M Section
61. A new patient is seen in the office for a variety of medical
problems.
The patient has insulin-dependent diabetes mellitus with
complicating
eye and renal problems. She also has hypertensive heart disease
with
episodes of congestive heart failure. Her peripheral vascular
disease has
Odd-oambered answers are located in Appendix B, whlle the
full answer key ls only available in the TBACH
Instrsctor Resources on Evolve.
Copyright O 2015 by Saunders, an imprint of Elsevier Inc. A11
rights reserved.
CHAPTER 15 r Evaluation and Management (T/Ml Ssrices
worsened, and she can walk only a block before she is crippled
with
extreme leg pain. The patient reports that a new problern has
surfaced
throbbing headaches with radiating neck pain. To manage and
investigate the multiplicity of problems, the physician performs
a
comprehensive history and physical examination. A complete
review of
systems is performed, as is an update to her complete past,
family, aad
social history. The physician has to take a multitude of factors
into
consideration because this patient's problems are highly
complex.
CPT Code:
./
1. Onew patient is seen in the office complaining of a sore
throat and
reports a low-grade fever for the past 4 days. The physician
performs an
expanded problem focused history and an expanded problem
focused
examination of the respiratory and lymphatic system. The
physician's
impression was acute pharyngitis and straightforward decision
making
was performed. Amoxicillin was prescribed.
CPT Code:
ICD-1O-CM Code:
(ICD-9-CM Code:
63. This is a 3}-year-old female patient admitted for
observation after an
allergic reaction to her pain medication. She is alert and
oriented, but
has severe pruritus and shortness of breath. A detailed history
and
examination is performed after she takes medication for the
pruritus;
the breathing improved and the patient was discharged from
observation on the same day.
CPT Code:
ICD-10-CM Codes:
(ICD-9-CM Codes:
The patient was admitted to the hospital 3 days ago with severe
dehydration and hyponatremia. The patient is now being
discharged-
Discharge takes 30 minutes.
CPT Code:
ICD-1O-CM Codes:
(ICD-9-CM Codes:
Odd-numbered answers are located in Appeadlx B, while the
full answer key is only aveibllc tr |lc IEA(E
Instructor Resources on Evolve.
Copyright @ 2015 by Saunders, an imprint of Elsevier Inc. A11
rights reserved.
J,^
CIL{PTER. 15 r Erzluation and Management (EM) Services
65. A family practice physician who is treating a ZO-year-old
man
(inpatient) for bronchitis calls in a urologist to examine the
patient,
who has requested a circumcision. The consultant performs a
problem
focused history and problem focused physical examination and
determines that there is no urgency for the surgical procedure.
The
physician's decision making is fairly straightforward, and he
recommends that the patient have the procedure done as an
outpatient
at a later date.
, CPT Code:
t-/
,/rU. O physician visits a 7S-year-old female in the extended
nursing facility
as part of her annual assessment. The physician completes a
detailed
interval history with a comprehensive, head-to-toe physical
examination. The physician reviews and affirms the medical
ptan of
care developed by the multidisciplinary care team at the nursing
facility. The patient's condition is stable; her hypertension and
diabetes
(type 2) are in good control and she has no new problems. The
physician has limited data to review and few diagnoses to
consider. The
MDM complexity was low.
CPT Code:
ICD-1O-CM Codes:
(ICD-9-CM Codes:
67. A 67-yearold female is admitted with severe exacerbation of
her COPD.
The patient is now in respiratory failure and CHF. The patient is
intubated and unconscious; 155 minutes of critical care time
was spent
at bedside and coordinating care for this patient.
& cpr code(s):
@ Ico-ro-cM code(s):
1& tco-o-cM code(s):
68. Henry Green, an established patient, came inte the office for
his yearly
physical examination. Henry is 72 and in good.health.
CPT Code:
ICD-10-CM Code:
(ICD-9-CM Code:
S ut r to decide number of codes necessary to correctly answer
the questlon.
Odrllrnhmd aD,:fiit-ens are located in Appendix B, while the
full answea key is only available in the TEACH
hfrxtor Besoqrccs on Evolve.
i
!
l
1
Copfight O 2015 by Saunders, an imprint of Elsevier Inc. All
dghts reserved.

More Related Content

Similar to CHAPTER 15 r Evaiuation and Management (EM) Services,fA,.docx

Pain in Sickle Cell Disease.pptx
Pain in Sickle Cell Disease.pptxPain in Sickle Cell Disease.pptx
Pain in Sickle Cell Disease.pptxkowiouABOUDOU1
 
85835716 case-study-elective1
85835716 case-study-elective185835716 case-study-elective1
85835716 case-study-elective1homeworkping3
 
1) It is 330 p.m. on a Thursday and Mr. B, a 67-year-old patien.docx
1) It is 330 p.m. on a Thursday and Mr. B, a 67-year-old patien.docx1) It is 330 p.m. on a Thursday and Mr. B, a 67-year-old patien.docx
1) It is 330 p.m. on a Thursday and Mr. B, a 67-year-old patien.docxdorishigh
 
Wardnursessepsis
WardnursessepsisWardnursessepsis
WardnursessepsisNeikaN
 
Workshop book for sir 2012 justin
Workshop book for sir 2012 justinWorkshop book for sir 2012 justin
Workshop book for sir 2012 justinpryce27
 
History taking a complete guide for all systems (clinical history & examinati...
History taking a complete guide for all systems (clinical history & examinati...History taking a complete guide for all systems (clinical history & examinati...
History taking a complete guide for all systems (clinical history & examinati...Updesh Yadav
 
History taking.pptxHistory taking.pptxHistory taking.pptx
History taking.pptxHistory taking.pptxHistory taking.pptxHistory taking.pptxHistory taking.pptxHistory taking.pptx
History taking.pptxHistory taking.pptxHistory taking.pptxssuser12303b
 
Drs. Potter and Richardson's CMC Pediatric X-Ray Mastery August Cases
Drs. Potter and Richardson's CMC Pediatric X-Ray Mastery August CasesDrs. Potter and Richardson's CMC Pediatric X-Ray Mastery August Cases
Drs. Potter and Richardson's CMC Pediatric X-Ray Mastery August CasesSean M. Fox
 
Hospital outbreak of middle east respiratory syndrome
Hospital outbreak of middle east respiratory syndromeHospital outbreak of middle east respiratory syndrome
Hospital outbreak of middle east respiratory syndromeDee Evardone
 
The Nuts And Bolts Of E&M Coding
The Nuts And Bolts Of E&M CodingThe Nuts And Bolts Of E&M Coding
The Nuts And Bolts Of E&M CodingAngie Nolan
 
preoperative preparation of surgical patient
preoperative preparation of surgical patient preoperative preparation of surgical patient
preoperative preparation of surgical patient tsedalemekete1
 
Pre Intra and Post Operative Care.pptx
Pre Intra and Post Operative Care.pptxPre Intra and Post Operative Care.pptx
Pre Intra and Post Operative Care.pptxAmmar hussain
 
Medical Information Retrieval Workshop Keynote (MedIR@SIGIR2014)
Medical Information Retrieval Workshop Keynote (MedIR@SIGIR2014)Medical Information Retrieval Workshop Keynote (MedIR@SIGIR2014)
Medical Information Retrieval Workshop Keynote (MedIR@SIGIR2014)Karin Verspoor
 
June 2016 IEP
June 2016 IEPJune 2016 IEP
June 2016 IEPskrentz
 
History Takeing and Physical Examn..pdf
History  Takeing and Physical Examn..pdfHistory  Takeing and Physical Examn..pdf
History Takeing and Physical Examn..pdfAbdallaAli64
 

Similar to CHAPTER 15 r Evaiuation and Management (EM) Services,fA,.docx (20)

Phc part 2
Phc part 2Phc part 2
Phc part 2
 
Pain in Sickle Cell Disease.pptx
Pain in Sickle Cell Disease.pptxPain in Sickle Cell Disease.pptx
Pain in Sickle Cell Disease.pptx
 
85835716 case-study-elective1
85835716 case-study-elective185835716 case-study-elective1
85835716 case-study-elective1
 
1) It is 330 p.m. on a Thursday and Mr. B, a 67-year-old patien.docx
1) It is 330 p.m. on a Thursday and Mr. B, a 67-year-old patien.docx1) It is 330 p.m. on a Thursday and Mr. B, a 67-year-old patien.docx
1) It is 330 p.m. on a Thursday and Mr. B, a 67-year-old patien.docx
 
HISTORY TAKING.pptx
HISTORY TAKING.pptxHISTORY TAKING.pptx
HISTORY TAKING.pptx
 
Wardnursessepsis
WardnursessepsisWardnursessepsis
Wardnursessepsis
 
Workshop book for sir 2012 justin
Workshop book for sir 2012 justinWorkshop book for sir 2012 justin
Workshop book for sir 2012 justin
 
Case history
Case historyCase history
Case history
 
History taking a complete guide for all systems (clinical history & examinati...
History taking a complete guide for all systems (clinical history & examinati...History taking a complete guide for all systems (clinical history & examinati...
History taking a complete guide for all systems (clinical history & examinati...
 
History taking.pptxHistory taking.pptxHistory taking.pptx
History taking.pptxHistory taking.pptxHistory taking.pptxHistory taking.pptxHistory taking.pptxHistory taking.pptx
History taking.pptxHistory taking.pptxHistory taking.pptx
 
Thomson poster proof
Thomson poster proofThomson poster proof
Thomson poster proof
 
Drs. Potter and Richardson's CMC Pediatric X-Ray Mastery August Cases
Drs. Potter and Richardson's CMC Pediatric X-Ray Mastery August CasesDrs. Potter and Richardson's CMC Pediatric X-Ray Mastery August Cases
Drs. Potter and Richardson's CMC Pediatric X-Ray Mastery August Cases
 
Hospital outbreak of middle east respiratory syndrome
Hospital outbreak of middle east respiratory syndromeHospital outbreak of middle east respiratory syndrome
Hospital outbreak of middle east respiratory syndrome
 
The Nuts And Bolts Of E&M Coding
The Nuts And Bolts Of E&M CodingThe Nuts And Bolts Of E&M Coding
The Nuts And Bolts Of E&M Coding
 
Nr 304 Rua
Nr 304 RuaNr 304 Rua
Nr 304 Rua
 
preoperative preparation of surgical patient
preoperative preparation of surgical patient preoperative preparation of surgical patient
preoperative preparation of surgical patient
 
Pre Intra and Post Operative Care.pptx
Pre Intra and Post Operative Care.pptxPre Intra and Post Operative Care.pptx
Pre Intra and Post Operative Care.pptx
 
Medical Information Retrieval Workshop Keynote (MedIR@SIGIR2014)
Medical Information Retrieval Workshop Keynote (MedIR@SIGIR2014)Medical Information Retrieval Workshop Keynote (MedIR@SIGIR2014)
Medical Information Retrieval Workshop Keynote (MedIR@SIGIR2014)
 
June 2016 IEP
June 2016 IEPJune 2016 IEP
June 2016 IEP
 
History Takeing and Physical Examn..pdf
History  Takeing and Physical Examn..pdfHistory  Takeing and Physical Examn..pdf
History Takeing and Physical Examn..pdf
 

More from bartholomeocoombs

CompetencyAnalyze how human resource standards and practices.docx
CompetencyAnalyze how human resource standards and practices.docxCompetencyAnalyze how human resource standards and practices.docx
CompetencyAnalyze how human resource standards and practices.docxbartholomeocoombs
 
CompetencyAnalyze financial statements to assess performance.docx
CompetencyAnalyze financial statements to assess performance.docxCompetencyAnalyze financial statements to assess performance.docx
CompetencyAnalyze financial statements to assess performance.docxbartholomeocoombs
 
CompetencyAnalyze ethical and legal dilemmas that healthcare.docx
CompetencyAnalyze ethical and legal dilemmas that healthcare.docxCompetencyAnalyze ethical and legal dilemmas that healthcare.docx
CompetencyAnalyze ethical and legal dilemmas that healthcare.docxbartholomeocoombs
 
CompetencyAnalyze ethical and legal dilemmas that healthcare wor.docx
CompetencyAnalyze ethical and legal dilemmas that healthcare wor.docxCompetencyAnalyze ethical and legal dilemmas that healthcare wor.docx
CompetencyAnalyze ethical and legal dilemmas that healthcare wor.docxbartholomeocoombs
 
CompetencyAnalyze collaboration tools to support organizatio.docx
CompetencyAnalyze collaboration tools to support organizatio.docxCompetencyAnalyze collaboration tools to support organizatio.docx
CompetencyAnalyze collaboration tools to support organizatio.docxbartholomeocoombs
 
Competency Checklist and Professional Development Resources .docx
Competency Checklist and Professional Development Resources .docxCompetency Checklist and Professional Development Resources .docx
Competency Checklist and Professional Development Resources .docxbartholomeocoombs
 
Competency 6 Enagage with Communities and Organizations (3 hrs) (1 .docx
Competency 6 Enagage with Communities and Organizations (3 hrs) (1 .docxCompetency 6 Enagage with Communities and Organizations (3 hrs) (1 .docx
Competency 6 Enagage with Communities and Organizations (3 hrs) (1 .docxbartholomeocoombs
 
Competency 2 Examine the organizational behavior within busines.docx
Competency 2 Examine the organizational behavior within busines.docxCompetency 2 Examine the organizational behavior within busines.docx
Competency 2 Examine the organizational behavior within busines.docxbartholomeocoombs
 
CompetenciesEvaluate the challenges and benefits of employ.docx
CompetenciesEvaluate the challenges and benefits of employ.docxCompetenciesEvaluate the challenges and benefits of employ.docx
CompetenciesEvaluate the challenges and benefits of employ.docxbartholomeocoombs
 
CompetenciesDescribe the supply chain management principle.docx
CompetenciesDescribe the supply chain management principle.docxCompetenciesDescribe the supply chain management principle.docx
CompetenciesDescribe the supply chain management principle.docxbartholomeocoombs
 
CompetenciesABCDF1.1 Create oral, written, or visual .docx
CompetenciesABCDF1.1 Create oral, written, or visual .docxCompetenciesABCDF1.1 Create oral, written, or visual .docx
CompetenciesABCDF1.1 Create oral, written, or visual .docxbartholomeocoombs
 
COMPETENCIES734.3.4 Healthcare Utilization and Finance.docx
COMPETENCIES734.3.4  Healthcare Utilization and Finance.docxCOMPETENCIES734.3.4  Healthcare Utilization and Finance.docx
COMPETENCIES734.3.4 Healthcare Utilization and Finance.docxbartholomeocoombs
 
Competencies and KnowledgeWhat competencies were you able to dev.docx
Competencies and KnowledgeWhat competencies were you able to dev.docxCompetencies and KnowledgeWhat competencies were you able to dev.docx
Competencies and KnowledgeWhat competencies were you able to dev.docxbartholomeocoombs
 
Competencies and KnowledgeThis assignment has 2 parts.docx
Competencies and KnowledgeThis assignment has 2 parts.docxCompetencies and KnowledgeThis assignment has 2 parts.docx
Competencies and KnowledgeThis assignment has 2 parts.docxbartholomeocoombs
 
Competencies and KnowledgeThis assignment has 2 partsWhat.docx
Competencies and KnowledgeThis assignment has 2 partsWhat.docxCompetencies and KnowledgeThis assignment has 2 partsWhat.docx
Competencies and KnowledgeThis assignment has 2 partsWhat.docxbartholomeocoombs
 
Competences, Learning Theories and MOOCsRecent Developments.docx
Competences, Learning Theories and MOOCsRecent Developments.docxCompetences, Learning Theories and MOOCsRecent Developments.docx
Competences, Learning Theories and MOOCsRecent Developments.docxbartholomeocoombs
 
Compensation  & Benefits Class 700 words with referencesA stra.docx
Compensation  & Benefits Class 700 words with referencesA stra.docxCompensation  & Benefits Class 700 words with referencesA stra.docx
Compensation  & Benefits Class 700 words with referencesA stra.docxbartholomeocoombs
 
Compensation, Benefits, Reward & Recognition Plan for V..docx
Compensation, Benefits, Reward & Recognition Plan for V..docxCompensation, Benefits, Reward & Recognition Plan for V..docx
Compensation, Benefits, Reward & Recognition Plan for V..docxbartholomeocoombs
 
Compete the following tablesTheoryKey figuresKey concepts o.docx
Compete the following tablesTheoryKey figuresKey concepts o.docxCompete the following tablesTheoryKey figuresKey concepts o.docx
Compete the following tablesTheoryKey figuresKey concepts o.docxbartholomeocoombs
 
Compensation Strategy for Knowledge WorkersTo prepare for this a.docx
Compensation Strategy for Knowledge WorkersTo prepare for this a.docxCompensation Strategy for Knowledge WorkersTo prepare for this a.docx
Compensation Strategy for Knowledge WorkersTo prepare for this a.docxbartholomeocoombs
 

More from bartholomeocoombs (20)

CompetencyAnalyze how human resource standards and practices.docx
CompetencyAnalyze how human resource standards and practices.docxCompetencyAnalyze how human resource standards and practices.docx
CompetencyAnalyze how human resource standards and practices.docx
 
CompetencyAnalyze financial statements to assess performance.docx
CompetencyAnalyze financial statements to assess performance.docxCompetencyAnalyze financial statements to assess performance.docx
CompetencyAnalyze financial statements to assess performance.docx
 
CompetencyAnalyze ethical and legal dilemmas that healthcare.docx
CompetencyAnalyze ethical and legal dilemmas that healthcare.docxCompetencyAnalyze ethical and legal dilemmas that healthcare.docx
CompetencyAnalyze ethical and legal dilemmas that healthcare.docx
 
CompetencyAnalyze ethical and legal dilemmas that healthcare wor.docx
CompetencyAnalyze ethical and legal dilemmas that healthcare wor.docxCompetencyAnalyze ethical and legal dilemmas that healthcare wor.docx
CompetencyAnalyze ethical and legal dilemmas that healthcare wor.docx
 
CompetencyAnalyze collaboration tools to support organizatio.docx
CompetencyAnalyze collaboration tools to support organizatio.docxCompetencyAnalyze collaboration tools to support organizatio.docx
CompetencyAnalyze collaboration tools to support organizatio.docx
 
Competency Checklist and Professional Development Resources .docx
Competency Checklist and Professional Development Resources .docxCompetency Checklist and Professional Development Resources .docx
Competency Checklist and Professional Development Resources .docx
 
Competency 6 Enagage with Communities and Organizations (3 hrs) (1 .docx
Competency 6 Enagage with Communities and Organizations (3 hrs) (1 .docxCompetency 6 Enagage with Communities and Organizations (3 hrs) (1 .docx
Competency 6 Enagage with Communities and Organizations (3 hrs) (1 .docx
 
Competency 2 Examine the organizational behavior within busines.docx
Competency 2 Examine the organizational behavior within busines.docxCompetency 2 Examine the organizational behavior within busines.docx
Competency 2 Examine the organizational behavior within busines.docx
 
CompetenciesEvaluate the challenges and benefits of employ.docx
CompetenciesEvaluate the challenges and benefits of employ.docxCompetenciesEvaluate the challenges and benefits of employ.docx
CompetenciesEvaluate the challenges and benefits of employ.docx
 
CompetenciesDescribe the supply chain management principle.docx
CompetenciesDescribe the supply chain management principle.docxCompetenciesDescribe the supply chain management principle.docx
CompetenciesDescribe the supply chain management principle.docx
 
CompetenciesABCDF1.1 Create oral, written, or visual .docx
CompetenciesABCDF1.1 Create oral, written, or visual .docxCompetenciesABCDF1.1 Create oral, written, or visual .docx
CompetenciesABCDF1.1 Create oral, written, or visual .docx
 
COMPETENCIES734.3.4 Healthcare Utilization and Finance.docx
COMPETENCIES734.3.4  Healthcare Utilization and Finance.docxCOMPETENCIES734.3.4  Healthcare Utilization and Finance.docx
COMPETENCIES734.3.4 Healthcare Utilization and Finance.docx
 
Competencies and KnowledgeWhat competencies were you able to dev.docx
Competencies and KnowledgeWhat competencies were you able to dev.docxCompetencies and KnowledgeWhat competencies were you able to dev.docx
Competencies and KnowledgeWhat competencies were you able to dev.docx
 
Competencies and KnowledgeThis assignment has 2 parts.docx
Competencies and KnowledgeThis assignment has 2 parts.docxCompetencies and KnowledgeThis assignment has 2 parts.docx
Competencies and KnowledgeThis assignment has 2 parts.docx
 
Competencies and KnowledgeThis assignment has 2 partsWhat.docx
Competencies and KnowledgeThis assignment has 2 partsWhat.docxCompetencies and KnowledgeThis assignment has 2 partsWhat.docx
Competencies and KnowledgeThis assignment has 2 partsWhat.docx
 
Competences, Learning Theories and MOOCsRecent Developments.docx
Competences, Learning Theories and MOOCsRecent Developments.docxCompetences, Learning Theories and MOOCsRecent Developments.docx
Competences, Learning Theories and MOOCsRecent Developments.docx
 
Compensation  & Benefits Class 700 words with referencesA stra.docx
Compensation  & Benefits Class 700 words with referencesA stra.docxCompensation  & Benefits Class 700 words with referencesA stra.docx
Compensation  & Benefits Class 700 words with referencesA stra.docx
 
Compensation, Benefits, Reward & Recognition Plan for V..docx
Compensation, Benefits, Reward & Recognition Plan for V..docxCompensation, Benefits, Reward & Recognition Plan for V..docx
Compensation, Benefits, Reward & Recognition Plan for V..docx
 
Compete the following tablesTheoryKey figuresKey concepts o.docx
Compete the following tablesTheoryKey figuresKey concepts o.docxCompete the following tablesTheoryKey figuresKey concepts o.docx
Compete the following tablesTheoryKey figuresKey concepts o.docx
 
Compensation Strategy for Knowledge WorkersTo prepare for this a.docx
Compensation Strategy for Knowledge WorkersTo prepare for this a.docxCompensation Strategy for Knowledge WorkersTo prepare for this a.docx
Compensation Strategy for Knowledge WorkersTo prepare for this a.docx
 

Recently uploaded

Interactive Powerpoint_How to Master effective communication
Interactive Powerpoint_How to Master effective communicationInteractive Powerpoint_How to Master effective communication
Interactive Powerpoint_How to Master effective communicationnomboosow
 
SOCIAL AND HISTORICAL CONTEXT - LFTVD.pptx
SOCIAL AND HISTORICAL CONTEXT - LFTVD.pptxSOCIAL AND HISTORICAL CONTEXT - LFTVD.pptx
SOCIAL AND HISTORICAL CONTEXT - LFTVD.pptxiammrhaywood
 
The basics of sentences session 2pptx copy.pptx
The basics of sentences session 2pptx copy.pptxThe basics of sentences session 2pptx copy.pptx
The basics of sentences session 2pptx copy.pptxheathfieldcps1
 
BAG TECHNIQUE Bag technique-a tool making use of public health bag through wh...
BAG TECHNIQUE Bag technique-a tool making use of public health bag through wh...BAG TECHNIQUE Bag technique-a tool making use of public health bag through wh...
BAG TECHNIQUE Bag technique-a tool making use of public health bag through wh...Sapna Thakur
 
Student login on Anyboli platform.helpin
Student login on Anyboli platform.helpinStudent login on Anyboli platform.helpin
Student login on Anyboli platform.helpinRaunakKeshri1
 
Ecosystem Interactions Class Discussion Presentation in Blue Green Lined Styl...
Ecosystem Interactions Class Discussion Presentation in Blue Green Lined Styl...Ecosystem Interactions Class Discussion Presentation in Blue Green Lined Styl...
Ecosystem Interactions Class Discussion Presentation in Blue Green Lined Styl...fonyou31
 
General AI for Medical Educators April 2024
General AI for Medical Educators April 2024General AI for Medical Educators April 2024
General AI for Medical Educators April 2024Janet Corral
 
Unit-IV- Pharma. Marketing Channels.pptx
Unit-IV- Pharma. Marketing Channels.pptxUnit-IV- Pharma. Marketing Channels.pptx
Unit-IV- Pharma. Marketing Channels.pptxVishalSingh1417
 
Web & Social Media Analytics Previous Year Question Paper.pdf
Web & Social Media Analytics Previous Year Question Paper.pdfWeb & Social Media Analytics Previous Year Question Paper.pdf
Web & Social Media Analytics Previous Year Question Paper.pdfJayanti Pande
 
social pharmacy d-pharm 1st year by Pragati K. Mahajan
social pharmacy d-pharm 1st year by Pragati K. Mahajansocial pharmacy d-pharm 1st year by Pragati K. Mahajan
social pharmacy d-pharm 1st year by Pragati K. Mahajanpragatimahajan3
 
Explore beautiful and ugly buildings. Mathematics helps us create beautiful d...
Explore beautiful and ugly buildings. Mathematics helps us create beautiful d...Explore beautiful and ugly buildings. Mathematics helps us create beautiful d...
Explore beautiful and ugly buildings. Mathematics helps us create beautiful d...christianmathematics
 
Grant Readiness 101 TechSoup and Remy Consulting
Grant Readiness 101 TechSoup and Remy ConsultingGrant Readiness 101 TechSoup and Remy Consulting
Grant Readiness 101 TechSoup and Remy ConsultingTechSoup
 
Z Score,T Score, Percential Rank and Box Plot Graph
Z Score,T Score, Percential Rank and Box Plot GraphZ Score,T Score, Percential Rank and Box Plot Graph
Z Score,T Score, Percential Rank and Box Plot GraphThiyagu K
 
Measures of Central Tendency: Mean, Median and Mode
Measures of Central Tendency: Mean, Median and ModeMeasures of Central Tendency: Mean, Median and Mode
Measures of Central Tendency: Mean, Median and ModeThiyagu K
 
APM Welcome, APM North West Network Conference, Synergies Across Sectors
APM Welcome, APM North West Network Conference, Synergies Across SectorsAPM Welcome, APM North West Network Conference, Synergies Across Sectors
APM Welcome, APM North West Network Conference, Synergies Across SectorsAssociation for Project Management
 
Disha NEET Physics Guide for classes 11 and 12.pdf
Disha NEET Physics Guide for classes 11 and 12.pdfDisha NEET Physics Guide for classes 11 and 12.pdf
Disha NEET Physics Guide for classes 11 and 12.pdfchloefrazer622
 
Class 11th Physics NEET formula sheet pdf
Class 11th Physics NEET formula sheet pdfClass 11th Physics NEET formula sheet pdf
Class 11th Physics NEET formula sheet pdfAyushMahapatra5
 
The Most Excellent Way | 1 Corinthians 13
The Most Excellent Way | 1 Corinthians 13The Most Excellent Way | 1 Corinthians 13
The Most Excellent Way | 1 Corinthians 13Steve Thomason
 
Nutritional Needs Presentation - HLTH 104
Nutritional Needs Presentation - HLTH 104Nutritional Needs Presentation - HLTH 104
Nutritional Needs Presentation - HLTH 104misteraugie
 

Recently uploaded (20)

Interactive Powerpoint_How to Master effective communication
Interactive Powerpoint_How to Master effective communicationInteractive Powerpoint_How to Master effective communication
Interactive Powerpoint_How to Master effective communication
 
SOCIAL AND HISTORICAL CONTEXT - LFTVD.pptx
SOCIAL AND HISTORICAL CONTEXT - LFTVD.pptxSOCIAL AND HISTORICAL CONTEXT - LFTVD.pptx
SOCIAL AND HISTORICAL CONTEXT - LFTVD.pptx
 
The basics of sentences session 2pptx copy.pptx
The basics of sentences session 2pptx copy.pptxThe basics of sentences session 2pptx copy.pptx
The basics of sentences session 2pptx copy.pptx
 
BAG TECHNIQUE Bag technique-a tool making use of public health bag through wh...
BAG TECHNIQUE Bag technique-a tool making use of public health bag through wh...BAG TECHNIQUE Bag technique-a tool making use of public health bag through wh...
BAG TECHNIQUE Bag technique-a tool making use of public health bag through wh...
 
Student login on Anyboli platform.helpin
Student login on Anyboli platform.helpinStudent login on Anyboli platform.helpin
Student login on Anyboli platform.helpin
 
Ecosystem Interactions Class Discussion Presentation in Blue Green Lined Styl...
Ecosystem Interactions Class Discussion Presentation in Blue Green Lined Styl...Ecosystem Interactions Class Discussion Presentation in Blue Green Lined Styl...
Ecosystem Interactions Class Discussion Presentation in Blue Green Lined Styl...
 
General AI for Medical Educators April 2024
General AI for Medical Educators April 2024General AI for Medical Educators April 2024
General AI for Medical Educators April 2024
 
Unit-IV- Pharma. Marketing Channels.pptx
Unit-IV- Pharma. Marketing Channels.pptxUnit-IV- Pharma. Marketing Channels.pptx
Unit-IV- Pharma. Marketing Channels.pptx
 
Web & Social Media Analytics Previous Year Question Paper.pdf
Web & Social Media Analytics Previous Year Question Paper.pdfWeb & Social Media Analytics Previous Year Question Paper.pdf
Web & Social Media Analytics Previous Year Question Paper.pdf
 
social pharmacy d-pharm 1st year by Pragati K. Mahajan
social pharmacy d-pharm 1st year by Pragati K. Mahajansocial pharmacy d-pharm 1st year by Pragati K. Mahajan
social pharmacy d-pharm 1st year by Pragati K. Mahajan
 
Explore beautiful and ugly buildings. Mathematics helps us create beautiful d...
Explore beautiful and ugly buildings. Mathematics helps us create beautiful d...Explore beautiful and ugly buildings. Mathematics helps us create beautiful d...
Explore beautiful and ugly buildings. Mathematics helps us create beautiful d...
 
Grant Readiness 101 TechSoup and Remy Consulting
Grant Readiness 101 TechSoup and Remy ConsultingGrant Readiness 101 TechSoup and Remy Consulting
Grant Readiness 101 TechSoup and Remy Consulting
 
Z Score,T Score, Percential Rank and Box Plot Graph
Z Score,T Score, Percential Rank and Box Plot GraphZ Score,T Score, Percential Rank and Box Plot Graph
Z Score,T Score, Percential Rank and Box Plot Graph
 
Measures of Central Tendency: Mean, Median and Mode
Measures of Central Tendency: Mean, Median and ModeMeasures of Central Tendency: Mean, Median and Mode
Measures of Central Tendency: Mean, Median and Mode
 
Mattingly "AI & Prompt Design: Structured Data, Assistants, & RAG"
Mattingly "AI & Prompt Design: Structured Data, Assistants, & RAG"Mattingly "AI & Prompt Design: Structured Data, Assistants, & RAG"
Mattingly "AI & Prompt Design: Structured Data, Assistants, & RAG"
 
APM Welcome, APM North West Network Conference, Synergies Across Sectors
APM Welcome, APM North West Network Conference, Synergies Across SectorsAPM Welcome, APM North West Network Conference, Synergies Across Sectors
APM Welcome, APM North West Network Conference, Synergies Across Sectors
 
Disha NEET Physics Guide for classes 11 and 12.pdf
Disha NEET Physics Guide for classes 11 and 12.pdfDisha NEET Physics Guide for classes 11 and 12.pdf
Disha NEET Physics Guide for classes 11 and 12.pdf
 
Class 11th Physics NEET formula sheet pdf
Class 11th Physics NEET formula sheet pdfClass 11th Physics NEET formula sheet pdf
Class 11th Physics NEET formula sheet pdf
 
The Most Excellent Way | 1 Corinthians 13
The Most Excellent Way | 1 Corinthians 13The Most Excellent Way | 1 Corinthians 13
The Most Excellent Way | 1 Corinthians 13
 
Nutritional Needs Presentation - HLTH 104
Nutritional Needs Presentation - HLTH 104Nutritional Needs Presentation - HLTH 104
Nutritional Needs Presentation - HLTH 104
 

CHAPTER 15 r Evaiuation and Management (EM) Services,fA,.docx

  • 1. CHAPTER 15 r Evaiuation and Management (E/M) Services ,/fA, four types of medical decision making, in order of complexity from most to List the fi least risk ,d--A- A- ,lr, -lr- Inpatient time spent at the bedside or nursing station during or after the visit is what kind of time? 21. Thepatient's will reflect the . nrm-ber of systems examined by a brief statement of the findings. /ZZ. I discussion with a patient andlor family concerning one or more of the following areas: diagnostic results, impressions and/or recommended diagnostic studies; prognosis; risks and benefits of treatment; instruciions for treatment; importance of compliance with treatment; risk factor reduction; and patient and family education is
  • 2. 23. The history is the physician. information the Patient tells the Ol4r11bcrd .rasvl-crs are located in Appendix B, while the full answer key ls only available in the TEACE Iffir Ecsorrrces on Erolve. -4 ,r{ /n. ,{ 13. Complexity of medical decision making is based on three ve types of presenting problems from the most risk and least recovery to and most recovery: 19. Counseling and coordination of care are what kind of factors in most cases? U/O. ,r*"that is used as a guide for outpatient services is what kind of time? Cop].right @ 2015 by Saunders, an impdnt of Elsevier Inc' A1I rights reserved'
  • 3. CHAI{ER 15 r Evaluation and Management (E/l[l Sersices 6n. ,n"re is no distinction made between the new and established patients in this service department of a hospital: 25. Those services rendered by a physician whose opinion or advice is requested by another physician or agency in the evaluation and/or treatment of a patient is a(n) whereas the physician who has primary responsibility for the patient in the hospital is called r'26. Whencritically ill patients in medical emergencies require the constant attendance of the physician (e.g., cardiac arrest, shock, bleeding, and respiratory failure) to stabilize them, what kind of care is needed? 27. When care is provided same patient by more conditions, the care is for similar services than one physician (e.g., hospital visits) to the on the same day for different
  • 4. ,6. *nuris the name for the assumption of the total or speciflc care of a patient from one physician to another that does not constitute a consultation? 29. An inventory of body systems obtained signs and/or symptoms that the patient ."{o. ,tthe physician who is standing by does so for 25 minutes, can he ot she round the time up to 30 minutes for reporting purposes? through questioning to identifY may be experiencing is a(n) of Odd-numbered answers are located in Appendlx B, while the full answer key is only avaitrablc ir ft TEI'€E Instructor Resources on Evolve. Copyright @ 2015 by Saunders, an imprint of Elsevier Inc. A11 rights reserved. CIL{PTER 15 r fyil*5on irnd Management (E/}vf) Services PRACTICAT Office or Other Outpatlent Services and Hospltal lnpatient Service With the use of the CPT and ICD-10-CM/ICD-9-CM manuals, camplete the following:
  • 5. 3. Analyze this case in which the patient record states: 40-year- old male patient (new) is evaluated for contusion of a finger. The history and examination were problem focused. a. Diagnosis and management options for contusion of finger. (Options can be minimal, limited, multiple, or extensive.) Diagnosis and management options: Data to review to provide service. (Data can be minimal/none, limited, moderate, or extensive.) Only data available are current information obtained during the visit. Data: b. Risks if left untreated. (Risk can be minimal, Risks: low, moderate, or high.) c. All three of the elements have been met to qualify this patient for what level of decision making complexity? d. The patient record indicates that a problem focused history and examination were done. When this is combined with the level of decision-making complexity you arrived at for this patient, what is for 48 hours is discharged
  • 6. from the hospital. The patient was being observed after a motor vehicle accident for subdural hematoma, subsequently ruled out. Code onty the discharge services and diagnosis. CPT Code: ICD-1O-CM Codes: (ICD-9-CM Codes: 33. Initial observation of a patient was for upper abdominal pain, dizziness, and anemia. A comprehensive history and examination was performed. Moderate complexity decision making was conducted to admit the patient to observation to treat and rule out causes of the patient,s anemia. CPT Code: (nrnbcrcd arlsrYers are located in Appendix B, while the full answer key is only available ln the TEACH hltrrcfa fcrm,ccs oa Evolve. the correct CPT code for the case? Code: {32. A patient who was on observation status Copr.right @ 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved.
  • 7. CHAPTER 15 r Evaluation a.n; 0nmw:3, /74. A 16-year-old female is being admitted by her familr rorffir:u , with a 2-week history of fatigue and fever. It has b€en SW,'l* getting worse. She is suffering from dehydration. The F.xr.: - performs a comprehensive history to look for explanab;n: r"r fatigue, including recent activity level and recent sleep [:.a:m: detailed examination is performed and she is diagnosed -w: mononucleosis and admitted for treatment. CPT Code: ICD-10-CM Codes: (lCD-9-CM Codes: 35. A 56-year-old male with an established history of ASHD of natire arteries and past stent placement is admitted through the emerger::*, room with acute onset of chest pain. An EKG was performed and troponin levels taken. Both showed evidence of the patient having a:: acute inferior wall myocardial infarction. The cardiologist performs a comprehensive history, with the chief complaint, 4 from the histon c: present illness (HPI), a complete review of systems (ROS), and past, family, and social history (PFSH). The history includes the information that the pain started a week ago but last night worsened. Also on a scale
  • 8. of 1 to 10, he rated the pain an 8. It was also discovered that the patient has not been attending regular appointments in the clinic setting. A comprehensive examination was performed along with high- complexity medical decision making (MDM), including management of the patient's acute MI and reviewing data of the medical history of the patient. He was taken immediately to the cardiac catheterization lab to look for the source for the patient's ML CPT Code: ICD-1O-CM Codes: (ICD-9-CM Codes: /36. Th"patient is a 34-year-old established patient seen in the clinic by her dermatologist. She is followed for extensive psoriasis involving her scalp, trunk, and arms. It has now worsened and spread to her palms, and she is now also complaining of ioint pain. The spread to her hands has made it difficult to do many of her day-to-day tasks. A detailed history and examination are performed. The examination includes inspection of the affected areas in addition to bending and rotation of joints. A long discussion took place regarding a change in her medications to try to gain better control of her psoriasis and slow down the systemic progression. Topical and systemic treatment was decided on.
  • 9. CPT Code: ICD-10-CM Codes: (ICD-9-CM Codes: Odd'numbered answers are located in Appendix B, while the full answer key is only available in the TE-.,CH Instructor Resources on Evolve. Copyright @ 2015 by Saunders, an imprint of Elsevier inc. Al1 rights reserr.,ed. :":--rJll} :: I 3;- -{ l!-yearold boy with bacterial pneumonia is ho5pitalized and has had 5 days of antibiotic therapy. Today the child developed a fever of 101' F rtith a mild rash on his tofso. In a subsequent hospital visit, the attending physician performed a problem focused history and examination. The MDM complexity was low. CPT Code: ICD-1O-CM Code: (ICD-9-CM Code: *46. fne patient is a 52-year-old male from out of state visiting his daughter. He left his medications for his benign hypertension at home and is now
  • 10. here in the clinic in need of a prescription. A problem focused history and examination is performed and a prescription is given to the patient. CPT Code: ICD-10-CM Code: (ICD-9-CM Code: Consultation Services 39. A 47-year-old female was sent by her family practice physician for an office consultation with a gynecologist. The patient has been suffering with moderate pelvic pain, a heavy sensation in her lower pelvis, and marked discomfort during sexual intercourse. In a detailed history, the gynecologist noted the location, severity, and duration of her pelvic pain and related symptoms. In the review of systems, the patient had positive findings related to her gastrointestinal, genitourinary, and endocrine body systems. The physician noted that her medical history was noncontributory to the present problem. The detailed physical examination centered on her gastrointestinal and genitourinary systems, with a complete pelvic examination. The physician ordered laboratory tests and a pelvic ultrasound to determine uterine fibroids,
  • 11. endometritis, or other internal gynecological pathology. The MDM complexity was moderate. CPT Code: ICD-10-CM Codes: (ICD-9-CM Codes: lO. A38-year-old female has severe low back pain due to a trauma injury she experienced as a factory worker 4 years ago. The chronic pain has become almost unbearable, and her internal medicine physician cannot go any further with her treatment. An initial outpatient consultation is requested and the patient is sent to see the pain management specialist for suggestions to control the chronic pain. A comprehensive history is taken, including all of the pertinent information regarding her iniury. During the comprehensive examination the patient's gait and Odd-numbered answers are located in Appendlx B, while the full answer key is only avallable in the TEACH Instructor Resources on Evolve. Coplaight @ 2015 by Saunders, an imprint of Elsevier Inc. All rights reserved. CHA?TER 15 r Evaluation arld {anagement rBUt Senices
  • 12. movement were obselved. Moderate-complexit-V decision maliing is peformed, including different treatment options' A separate not€ is di.tut"d to show thirequesting physician what results rt"ere found during the visit and the decision on treatment of her pain' CPT Code: ICD-10-CM Codes: (ICD-9-CM Codes: CPT Code: CPT Code: ICD-10-CM Code: (ICD-9-CM Code: 41. An inpatient urological consultation is performed for a 3}- yearold female who recentiy had an elective abortion performed on an outpatient basis. The woman has been admitted with a high fever, pelvic pain, and dysuria. During a detailed history, the urologist notes in the irirtory of piesent illness that the patient's symptoms began abortt 2
  • 13. days ifter ihe abortion and progressed to the acute phase, which she is in at the present time. The lbcation of the pain is in the lower abdomen and rated 9 on a scale of 1 to 10. She reports the quality of the pain to be sharp and stabbing. In the review of systems, the physician notes positive responses in 5 of the L2 body systems investigated. The urologist notes a negative medical history related to urinary symptoms other-than a mild.frtitl. about 10 years ago. The detailed physical examination performed by the urologist centels on the genitourinary system and gistrointestinil system in significant detail..The medical decision making is low. Given the patient's past surgical procedure and physical findinfs at the present, the consultant considers the diagnoses of pyelonephritis, cystitis, pyelitis, and endometritis' ',) ,d. O46-year-old male is admitted to the hospital with a progressive staptrylococcal pneumonia that is not responding to treatment' A r"qr.it is made for the infectious disease physician on staff to
  • 14. render his opinion for treatment. The patient is seen in initial inpatient .onrrltation. An expanded problem focused history and examination are performed. Aftei looking at the sputum cultures, t{: PhYsician decides on the most effective antibiotic for treatment' The decision making is straightforward. 43. The initial consulting physician subsequently sees a Ss- year-old patient injured at work whei -he"fell from a house roof and struck his head- The patient had a right frontal parietal craniotomy 6 days previousll'and is iecovering rapidly. The initial consultation was requested regarding a possible d-rug reactlon that produced a rash on the uppel torso. The- consultant ricommended a medication change, but after 48 hours t1.e patient had no improvement. The physician re-evaluates for other possible causes of ifre rash. An expanded problem focused inten-al Odd-numbered answers are located in Appendix B, while the full answer key is only available in th€ IEACE
  • 15. Instrrrctor Resources on Evolve. copyright @ 2015 by Saunders, an imprint of Elsevier Inc. A11 rights reserved. CFLPTER 15 r Evaluation and Management (E/M) Services history and a physical examination were performed. The MDM complexity was moderate. CPT Code: ICD-10-CM Code: (ICD-9-CM Code: /++. l,44-year-old patient, with chronic mastoiditis, was seen in consultation by the ENT specialist in the office. Her physician was inquiring as to the advantages of surgery versus continued antibiotic treatment when an acute flare comes on. The ENT specialist recommends surgery because of the increasing severity with each acute flare. She is fearful of the surgery because of the need to go under general anesthetic and a fear of permanent hearing loss. The physician performs an expanded problem focused history to include the duration of this problem and how many acute flares ayear the patient experiences. An expanded problem focused examination and straightforward decision making is completed. It is determined
  • 16. that with the number of acute flares a year and the increasing severity of each case that surgery is recommended. The patient's fears are laid to rest and the patient decides to go ahead with the surgery. CPT Code: ICD-10-CM Code: (ICD-9-CM Code: 45. This is a follow-up visit on a Z9-year-old male who is admitted with the diagnosis of headlches. The patient is subsequeptly seen because the physician needs to follow up on test results that weren't back yet at the initial consultation. This wiii help to find a possible cause of the headaches and course of treatment. A problem focused history and examination and low-complexity decision making is made after viewing the CT results. The diagnosis of tension headaches was made and treatment options discussed. CPT Code: ICD-10-CM Code: (ICD-9-CM Code: u/+0. An 83-year-old patient is seen at the local nursing home.
  • 17. The patient- suffers from severe COPD. Routine labs were drawn on the patient by her primary doctor and her blood sugar came back abnormal. Fasting glucose was then taken and was high. The endocrinologist was asked to render an opinion on a possible diagnosis of diabetes. A problem focused history and examination and straightforward decision making were made. Diabetes was diagnosed and treatment started. The endocrinologist contacted the primary physician and discussed treatment of the patient. Report services for the endocrinologist only. Odd-numbered ansrf,ers are located in Appendix B, whlle the full answer key is onty available in the TEACII Instructor Resources on Evolve. Copyright @ 2015 by Saunders, an impdnt of Elsevier Inc. All rights reserved. CHAPIER 15 r Evaluation and Managem€rt rE]{i Strr-x: CPT Code: ICD-10-CM Code: (ICD-9-CM Code: 47. Apatient is sent to a general surgeon by her family physician for an oplnion and recommendation for surgical repair of a recurrent
  • 18. femoral hernia, right. A brief problem focused history of present illness and a problem focused examination of the affected body area and organ system are performed in the office. The MDM complexity was straightforward. CPT Code: ICD-IO-CM Code: (ICD-9-CM Code: ,r/+5. I pulmonologist is asked, by the patient's primary physician, to see a 14-month-old boy who was admitted to the hospital with respiratory distress, cough, and fever. A comprehensive history is taken from the . parents because this is an infant. It was determined that the patient' does attend a day care facility. The cough and fever have been present for approximately 5 days. The infant stalted having trouble breathing this morning. The patient is intubated. Pneumonia due to respiratory syncytial virus is the definitive diagnosis. A comprehensive examination ii peiformed along with moderate decision making. More tests will follow. A copy of his dictation will be sent to the primary physician.
  • 19. CPT Code: ICD-10-CM Code: (ICD-9-CM Code: 49. Office neurosurgery consultation is requested by the primary physician fot a 3Z-year-old man on workers' compensation who is unable to work because of displacement of intervertebral lumbar disc with myelopathy. TWo previous surgical repairs have been unsuccessful in relieving the patient's pain. The patient has been unable to return to his employmint as a bricklayer. He complains of radiating pain throughout the buttocks and leg, with numbness throughout the leg and foot. Reflexes are minimal to nonexistent. A comprehensive history and physical examination are performed. MDM complexity was high due to the prior surgeries and continued complaints. CPT Code: ICD-10-CM Code: (ICD-9-CM Code: Odd-numbered answers are Iocated in Appendix B, while the full answer key is only available in thc TE{(f, Instructor Resources on Evolve.
  • 20. Copyright @ 2015 by Saunders, an imprint of Elsevier Inc. All rights teserved. C}L{PTER 1S r Er-aluation and {anagement (E/M) Services Emergency Department Services, Nursing Facility, Domiciliary and Home Services ,iO. A patient presents to the emergency department after being involved in a motor vehicle accident. The patient was wearing a seat belt. The vehicle rolled numerous times. The patient's head struck the side window. The patient is unresponsive and is intubated. A history was unable to be obtained because of the patient's unresponsiveness. What history is available comes from the paramedics and patient's record. A comprehensive examination reveals the abdomen to be quite swollen with extensive bruising around the lower abdomen caused by the seat belt. High-complexity decision making was involved and the patient was rushed to the operating room. CPT Code: 51. A male patient presents to the emergency department with a wrist sprain sustained in a softball game when the patient slid into home,
  • 21. striking his hand on home plate. The patient is in apparent pain with a swollen wrist, which he is unable to flex. An expanded problem focused history and physical examination are done. Rad?ographs show a CoIIes' fracture of the distal radius. The MDM complexity was low. CPT Code: ICD-10-CM Codes: (ICD-9-CM Codes: ,./SZ. An 88-year-old female's family physician comes to the nursing facility to perform the resident's annual assessment. A detailed interval history is taken with some information from the patient, but because of her limited cognitive abilities, most of the information is gathered from the nurses and past records. A comprehensive multisystem physical examination is performed, which includes extensive body areas and related organ systems. The MDM complexity was moderate because multiple diagnoses must be considered for this patient, who has senile dementia, diabetes, hypertension, hypothyroidism, and recurrent transient ischemic attacks. The creation of a new treatment plan is required because some of the patient's conditions have worsened. CPT Code:
  • 22. ICD-10-CM Codes: (ICD-9-CM Codes: Odd-numbered answers are located in Appendix B, while the full answer key is only avallable ln the TEACH Instructor Resources on Evolve. Copyright @ 2015 by Saunders, an impdnt of Elsevier Inc. A11 rights reserved. CHAPTER 1.5 r f1-n1g31ion ard 1.:-,:. _-..:.: : l.: :=.- 53' This is a home visit on an elderly gentleman, pre'ioush'i.inrr- -,, r-- lme, who is complaining of edemaln his iowei extremirics. f ;-r. -iassociated with this. An expanded problem focused histor:,. a:; examination are performed and ro* complexity decisior, *uiJ.. _stockings are prescribed. CPT Code: /54. subsequent foilow-up care is provided for the B2-year-old mare nursingfacility patient with Alzheimelr's disease. The resident has respondedwell to some new medications and appears to have recovered some ofhis cognitive abilities without behavioral disturbances. The physicianperforms a problem focused history and physicar examination on hisnerrrological problem and orders the current treatments continued. TheMDM complexity is low. CPT Code:
  • 23. ICD-1O-CM Code: (ICD-9-CM Code: ICD-1O-CM Codes: (ICD-9-CM Codes: 55. Subsequent follow-up care is provided for the patient who was transferred to a skilled nursing facility from an'acute care hospital afterpartial recovery from.a stroke-The pitient has deveroped periods ofextreme dizziness and mental confusion. A detailed iiterval historv isgathered, and a detailed physical examination of the "ff".i;; b.;; " systems is performed. Given the possibility that a new stroke could ha'eoccurred or that other neurological problems have developed, neworders are written, and the ptrysician plans to return the next day toevaluate the patient's condition again. The MDM compiexity is moderate. CPT Code: ICD-10-CM Codes: (ICD-9-CM Codes: copyright @ 2015 by Saunders, an imprint of Eisevier Inc. Alr rights reserr.ed. _-
  • 24. --.--------.-------.------.------..------.-._--) 146- the physician provides services to a resident of a rest home for,:,ulcerative sore on the heel and midfoot. Given the fact that ih.:-1r-.:r: is in reasonabry good health and is not diabetic, tne pn.:sic,";' -- ....his attention on the right lower extremity during the prcbl.::. - -.--._:physical examination. The physician knows the resideni ,.r;- 11_performs a brief HpI and ROS during a problem focused l_:: - - , , _,.resident thinks the sore is from new=shies, and the p.i.rl.-,-,_ ,. -,-_. odd-numbered answers are located in Appendix B, while the full answer kev is onl- a'ailable in the TE f HInstructor Resources on Evolve. r=il9[8. 15 r Srpa-,i"o ad ]arnrGffit ,Ef, Sersic.es with that corclusion. Topical antibiotic cream is ordered, and the new shoes are sent to the cobbler to be stretched. The MDM complexity is straightforward. CPT Code: ICD-IO-CM Code: flCD-g-CM Code: 57. The physician provides services to a new patient who is in a custodial care center. The patient is 43 years o1d and is paraplegic, with
  • 25. severe infected stasis ulcers. The physician performs a detailed history and examination and prescribes an antibiotic. The MDM was straightforward. CPT Code: Pyolonged Services and Preventive Medicine Services 4g. 'Mestablished patient is seen in the offlce for a new problem that requires a comprehensive history and examination. The MDM complexity is high, and the physician spends 40 minutes with the patient. However, the patient has numerous concerns, and the physician spends an additional hour and 50 minutes in prolonged direct patient contact. CPT Codes: 59. A 44-year-ord asthmatic patient (new) is scheduled for a routine office visit for a complaint of severe headaches. The physician provides a comprehensive history and examination. The MDM complexity was high. Toward the end of the visit, the patient develops severe breathing complications, and the physician spends the next hour and 30 minutes administering treatment. CPT Codes:
  • 26. / ,/OO. e 64-year-old man arrives at his appointment with his family physician for his annual physical examination. The patient has no new complaints and all of his medications remain the same. He is told to follow up in 1 year or sooner if necessary. CPT Code: Services from Throughout the E/M Section 61. A new patient is seen in the office for a variety of medical problems. The patient has insulin-dependent diabetes mellitus with complicating eye and renal problems. She also has hypertensive heart disease with episodes of congestive heart failure. Her peripheral vascular disease has Odd-oambered answers are located in Appendix B, whlle the full answer key ls only available in the TBACH Instrsctor Resources on Evolve. Copyright O 2015 by Saunders, an imprint of Elsevier Inc. A11 rights reserved. CHAPTER 15 r Evaluation and Management (T/Ml Ssrices worsened, and she can walk only a block before she is crippled with extreme leg pain. The patient reports that a new problern has
  • 27. surfaced throbbing headaches with radiating neck pain. To manage and investigate the multiplicity of problems, the physician performs a comprehensive history and physical examination. A complete review of systems is performed, as is an update to her complete past, family, aad social history. The physician has to take a multitude of factors into consideration because this patient's problems are highly complex. CPT Code: ./ 1. Onew patient is seen in the office complaining of a sore throat and reports a low-grade fever for the past 4 days. The physician performs an expanded problem focused history and an expanded problem focused examination of the respiratory and lymphatic system. The physician's impression was acute pharyngitis and straightforward decision making was performed. Amoxicillin was prescribed. CPT Code: ICD-1O-CM Code: (ICD-9-CM Code: 63. This is a 3}-year-old female patient admitted for observation after an
  • 28. allergic reaction to her pain medication. She is alert and oriented, but has severe pruritus and shortness of breath. A detailed history and examination is performed after she takes medication for the pruritus; the breathing improved and the patient was discharged from observation on the same day. CPT Code: ICD-10-CM Codes: (ICD-9-CM Codes: The patient was admitted to the hospital 3 days ago with severe dehydration and hyponatremia. The patient is now being discharged- Discharge takes 30 minutes. CPT Code: ICD-1O-CM Codes: (ICD-9-CM Codes: Odd-numbered answers are located in Appeadlx B, while the full answer key is only aveibllc tr |lc IEA(E Instructor Resources on Evolve. Copyright @ 2015 by Saunders, an imprint of Elsevier Inc. A11 rights reserved. J,^
  • 29. CIL{PTER. 15 r Erzluation and Management (EM) Services 65. A family practice physician who is treating a ZO-year-old man (inpatient) for bronchitis calls in a urologist to examine the patient, who has requested a circumcision. The consultant performs a problem focused history and problem focused physical examination and determines that there is no urgency for the surgical procedure. The physician's decision making is fairly straightforward, and he recommends that the patient have the procedure done as an outpatient at a later date. , CPT Code: t-/ ,/rU. O physician visits a 7S-year-old female in the extended nursing facility as part of her annual assessment. The physician completes a detailed interval history with a comprehensive, head-to-toe physical examination. The physician reviews and affirms the medical ptan of care developed by the multidisciplinary care team at the nursing facility. The patient's condition is stable; her hypertension and diabetes (type 2) are in good control and she has no new problems. The physician has limited data to review and few diagnoses to consider. The MDM complexity was low. CPT Code:
  • 30. ICD-1O-CM Codes: (ICD-9-CM Codes: 67. A 67-yearold female is admitted with severe exacerbation of her COPD. The patient is now in respiratory failure and CHF. The patient is intubated and unconscious; 155 minutes of critical care time was spent at bedside and coordinating care for this patient. & cpr code(s): @ Ico-ro-cM code(s): 1& tco-o-cM code(s): 68. Henry Green, an established patient, came inte the office for his yearly physical examination. Henry is 72 and in good.health. CPT Code: ICD-10-CM Code: (ICD-9-CM Code: S ut r to decide number of codes necessary to correctly answer the questlon. Odrllrnhmd aD,:fiit-ens are located in Appendix B, while the full answea key is only available in the TEACH hfrxtor Besoqrccs on Evolve. i
  • 31. ! l 1 Copfight O 2015 by Saunders, an imprint of Elsevier Inc. All dghts reserved.