Chapter 19: Evaluation and Management
A mother takes her 2-year-old back to Dr. Denton for an annual well child exam. The patient has a comprehensive checkup and vaccinations are brought up to date. Which category or subcategory of evaluation and management codes would be selected for the well child exam? A.Office visit, established patient B.Preventive medicine, established patient C.Subsequent hospital care D.Preventive medicine, individual counseling
Answer: B. Preventive medicine, established patient Rationale: The mother "takes her 2 year-old back to Dr. Denton" indicates this is an established patient. This is a well child exam with no complaints and a code from preventive medicine, established patient, would be selected. The preventive medicine, individual counseling codes are used for risk reduction such as diet and exercise, substance abuse, family problems, etc.
NEW PATIENT OFFICE VISIT CHIEF COMPLAINT: Low back pain with radiating pain into the legs. HISTORY OF PRESENT ILLNESS: A 78-year-old female with long-standing back pain. She is noted to have undergone previous epidurals. She has been diagnosed with spinal stenosis for approximately 10 years. She denies bowel or bladder dysfunction or saddle anesthesia. She offers a weakness of the extremity and numbness. She offers no unexpected weight loss, no recent trauma. She denies previous back surgery. She is a new patient to our office. CURRENT MEDICATIONS: Lisinopril, Lovastatin, glipizide, Arimidex, Naproxen, Neurontin, Xalatan, multivitamin. ALLERGIES: Codeine. PAST MEDICAL HISTORY: Breast cancer, hypertension, diabetes, prior history of spinal stenosis. REVIEW OF SYSTEMS: Denies any cardiac arrhythmia or unstable angina. No pulmonary disorders. Denies thyroid disease. No renal dysfunction. No history of stroke or seizure. She is without any unexpected weight loss or constitutional signs of infection. SOCIAL HISTORY: She is ambulatory without assist device. Denies tobacco and alcohol use. FAMILY HISTORY: Diabetes and cancer. PHYSICAL EXAMINATION: Side-to-side comparison shows no asymmetry, no pronounced atrophy. She has a pronounced straight leg raise on the right and also a contralateral straight leg raise on the left, but her discomfort is to a lesser degree. Reflexes are symmetric. Motor strength is noted to be 5/5 with ankle dorsi and plantar flexion, great toe extension, knee flexion/extension, hip abduction. She has 4/5 motor strength with hip flexion. Her hips are supple on examination. She has decreased sensation to L4-L5 level. ANCILLARY STUDIES: Independent interpretation of previous MRI from November 20XX shows evidence of spinal stenosis at L3-4, L4-5, and 5-S1. There is neural foramenal narrowing at these levels. Findings are most noted at L4-5. In addition, there is facet hypertrophy and ligamentous thickening. Cord maintained a normal signal. IMPRESSION: Spinal stenosis with radicular leg pain. PLAN: A repeat of the MRI will be obtained. She will return for reassessment following this study. Likely begin another course of epidural steroids. I have also recommended physical therapy. Further recommendations are pending her MRI. What E/M code is reported? A.99202 B.99203 C.99204 D.99205
Answer: C. 99204 Rationale: Established Patient Number and Complexity of Problems - One chronic illness with exacerbation - Moderate Amount and/or Complexity of Data to be Reviewed and Analyzed - Independent review of MRI and order of new MRI - Moderate Risk - Minor surgery with no additional risk factors and physical therapy - Low
During a soccer game, Ashley, a 26-year-old female, heard a popping sound in her knee. Her knee has been unstable since the incident and she decided to consult an orthopedist. She visits Dr. Howard, an orthopedist she has not seen before, to evaluate her knee pain. Dr. Howard's diagnosis is a torn ACL. What category and subcategory of evaluation and management code would be selected for the visit to Dr. Howard? A.Office visit, new patient B.Office visit, established patient C.Outpatient consultation D.Preventive visit, new patient
Answer: A. Office visit, new patient Rationale: Consultations performed at the request of a patient are coded using office visit codes. Because the patient has not seen Dr. Howard before, this would be considered a new patient visit.
NEW PATIENT OFFICE VISIT CHIEF COMPLAINT: Right inguinal hernia. HISTORY OF PRESENT ILLNESS: This 44-year-old athletic man has been aware of a bulge and a pain in his right groin for over a year. He is very active, both aerobically and anaerobically. He has a weight routine which he has modified because of this bulge in his right groin. Usually, he can complete his entire workout. He can swim and work without problems. Several weeks ago in the shower he noticed there was a bulge in the groin and he was able to push on it and make it go away. He has never had a groin operation on either side. The pain is minimal, but it is uncomfortable and it limits his ability to participate in his physical activity routine. In addition, he likes to do a lot of exercise in the back country and his personal physician, Dr. X, told him that it would be dangerous to have this become incarcerated in the back country. PAST MEDICAL HISTORY: Serious illnesses: Reactive airway disease for which he takes Advair. He is not on steroids and has no other pulmonary complaints. Operations: None. REVIEW OF SYSTEMS: He has no weight gain or weight loss. He has excellent exercise tolerance. He denies headaches, back pain, abdominal discomfort, or constipation. PHYSICAL EXAMINATION: VITAL SIGNS: Weight 82 kg, temperature 36.8, pulse 48 and regular, blood pressure 121/69. GENERAL APPEARANCE: He is a very muscular well-built man in no distress. SKIN: Normal. HEAD AND NECK: Sclerae are clear. External ocular eye movements are full. Trachea is midline. Thyroid is not felt. CHEST: Clear. HEART: Regular. ABDOMEN: Soft. Liver and spleen not felt. He has no abnormality in the left groin. In the right groin I can feel a silk purse sign, but I could not feel an actual mass. I am quite sure by history and by physical examination that he has a rather small indirect inguinal hernia. His cord and testicles are normal. NEURO: Grossly intact to motor and sensory examination. IMPRESSION: Right indirect inguinal hernia. PLAN: We discussed observation and repair. He is motivated toward repair and I described the operation in detail. I gave him the scheduling number and he will call and arrange the operation. What E/M code is reported? A.99202 B.99203 C.99204 D.99205
Answer: B. 99203 Rationale: New Patient Number and Complexity of Problems - One acute uncomplicated illness or injury - Low Amount and/or Complexity of Data to be Reviewed and Analyzed - None Risk - elective major surgery, no identified risk factors - Moderate
John, a 16-year-old male, is admitted by the emergency department physician for observation after an ATV accident. The patient is discharged from observation by another provider the next day. What category or subcategory of evaluation and management codes would be selected for the emergency department physician? A.Office visit, new patient B.Emergency department services C.Initial hospital care D.Initial observation care
Answer: D. Initial observation care Rationale: The patient presented to the Emergency Department and was admitted to observation by the ED physician. The guidelines for Initial Observation Care state that all services provided by the admitting physician for the same date of service are included in the initial hospital care, and in this instance the emergency department services would not be coded. If the patient was discharged on the same date of service, a code from Observation or Inpatient Care Services (Including Admission and Discharge Services) would be selected.
Medical Abbreviations
BP - Blood pressure CC - Chief complaint HEENT - Head, eyes, ears, nose, throat h/o - History of HPI - History of present illness Hx - History NAD - No apparent distress NKDA - No known drug allergies PE - Physical examination PERRLA - Pupils equal, round, and reactive to light and accommodation (for example, normal) PMH - Past medical history pt - Patient R/O - Rule out ROS - Review of systems WNL - Within normal limits
Physical Exam: General Appearance: Healthy appearing individual in no distress. Abdomen: Soft, non-tender, without masses. No CVA tenderness. Female Exam: Vulva/Labia Majora: No erythema, ulcerations, swelling, or lesions seen. Bartholin Glands: No cysts, abscesses, induration, discharge, masses, or inflammation noted. Skene's: No cysts, abscesses, induration, discharge, masses, or inflammation noted. Clitoris/Labia Minora: Clitoris normal. No atrophy, adhesions, erythema, or vesicles noted. Labia unremarkable. Urethral Meatus: Meatus appears normal in size and location. No masses, lesions, or prolapse. Urethra: No masses, tenderness, or scarring. Bladder: Without fullness, masses, or tenderness. Vagina: Mucosa clear without lesions, Pelvic support normal. No discharge. Cervix: The cervix is clear, firm, and closed. No visible lesions. No abnormal discharge. Uterus: Uterus non-tender and of normal size, shape, and consistency. Position and mobility are normal. Adnexa/Parametria: No masses or tenderness noted. Based on the 1995 Documentation Guidelines, what is the level of exam? A.Problem focused B.Expanded problem focused C.Detailed D.Comprehensive
. Answer: D. Comprehensive Rationale: Organ Systems: The documentation supports a comprehensive/complete single system (Female Genitourinary) exam. The level of exam is Comprehensive
ESTABLISHED PATIENT OFFICE VISIT DOS: 05/09/X1 CHIEF COMPLAINT: Left tibia fracture. HISTORY OF PRESENT ILLNESS: Patient is a 13-year-old male we first saw on 04/24/X1. He was noted to have been injured when he jumped and fell while running down a hill. He sustained a Salter-Harris II physeal fracture of the distal tibia. He is currently non-weight bearing in a short-leg cast. He has been compliant with his activity modifications. PHYSICAL EXAMINATION: He is intact to sensation. His capillary refill of the toes remains stable. There is no skin breakdown at the proximal or distal aspect of the cast. The cast is intact. ANCILLARY STUDIES: Radiographs ordered, performed, and billed in our office of the left ankle May 08, 20XX show good alignment and positioning of the fracture. Growth plate is stable. IMPRESSION: Left distal tibia fracture. PLAN: He will continue with the use of his cast, maintain non-weight bearing status. Return for reassessment with X-ray in two weeks. Cast care instructions are once again being reviewed. What E/M code is reported? A.99212 B.99213 C.99214 D.99215
Answer: B. 99213 Rationale: Established Patient Number and Complexity of Problems - One acute uncomplicated illness or injury - Low Amount and/or Complexity of Data to be Reviewed and Analyzed - Review of X-Ray - Minimal Risk - Non-weight bearing, cast care - Low
Physical Exam: General: His physical exam shows an intubated male. He is at times somewhat combative. There is a brace on the right shoulder. Skin: His skin is warm and dry. No rashes, ulcers, or lesions. Lungs: The lungs are diminished breath sounds, though no crackles are noted. Cardiac: Cardiac exam is tachycardic, no distinct murmurs appreciated. Extremities show no significant edema. Abdomen: Abdominal exam is soft. No masses or tenderness. No hepatosplenomegaly. Extremities: No clubbing or cyanosis. Bilateral lower: No misalignment or tenderness. Based on the 1995 Documentation Guidelines, what is the level of exam? A.Problem focused B.Expanded problem focused C.Detailed D.Comprehensive
Answer: C. Detailed Rationale: Organ Systems: Constitutional, Skin, Respiratory, Cardiovascular, Gastrointestinal, and Musculoskeletal. There are six organ systems examined with detailed documentation. The level of exam is Detailed.
Physical Exam: General: Alert, smiling child. HEENT: There is clear rhinorrhea. Pharynx is without inflammation. Neck: Supple. Chest: Lungs are clear without wheeze or rhonchi. Abdomen: Soft, nontender. What is the level of exam? A.Problem focused B.Expanded problem focused C.Detailed D.Comprehensive
Answer: B. Expanded problem focused Rationale: Body Areas: Neck, Abdomen Organ Systems: Constitutional, ENMT, Respiratory There are three organ systems examined and two Body Areas. This is a limited exam of the affected body areas. The level of exam is Expanded Problem Focused.
Dr. Hedrick, a neurosurgeon, was asked to assist in a surgery to remove cancer from the spinal cord. He acted as a co-surgeon working with an orthopedic surgeon. Dr. Hedrick followed up with the patient during his rounds at the hospital the next day. From what category or subcategory of evaluation and management services would Dr. Hedrick's follow-up visit be reported? A.Outpatient visit, established patient B.Inpatient consultation C.Non-billable D.Subsequent hospital care
Answer: C. Non-billable Rationale: The follow-up visit from the neurosurgeon the day following surgery is bundled in the surgical procedure and is not billable. The visit is within the global period of the procedure.
A 45-year-old patient is seeing the neurologist, Dr. Williams, at the request of his family physician to evaluate complaints of weakness, numbness, and pain in his left hand and arm. The pain started last year after rocks fell on him while mining. He still has significant, sharp, burning wrist pain and reports the problems are continuing to get worse. He is limited in his job as a machinist for a mining company due to the pain and numbness. He has no swelling in his hand, no neck pain, or radiating pain. His past medical history is negative for significant diseases. He has had carpal tunnel surgery. He has a family history of hypertension, heart disease, and stroke. He is married with children and smokes one pack of cigarettes/day. A detailed exam is performed of the mental status, cranial nerves, motor nerves, DTRs, sensory nerves, and head and neck. After performing an EMG and nerve conduction study, Dr. Williams determines the patient has left ulnar neuropathy at the cubital tunnel region, as well as an ongoing carpal tunnel syndrome. Repeat carpal tunnel surgery is recommended, along with a possible cubital tunnel surgical procedure. If the patient does not have surgery, he risks permanent nerve damage. A report is sent back to the physician requesting the consult. What is the appropriate E/M consultation code for this visit? A.99242 B.99243 C.99244 D.99245
Answer: B. 99243 Rationale: A consultation requires all three key components be met to support the level of visit. History—HPI (extended), ROS (Extended), PFSH (complete) = Detailed Exam—Detailed MDM—New problems no additional work-up, one data point given (review/order of test in medicine section) for the EMG or Nerve conduction study. The level of risk is moderate (elective major surgery). The documentation supports a 99243.
Mr. Andrews, a 34-year-old male, visits Dr. Parker's office at the request of Dr. Smith for a neurological consultation. He presents with complaints of weakness, numbness, and pain in his left hand and arm. Dr. Parker examines the patient and sends his recommendations and a written report back to Dr. Smith for the care of the patient. Which category or subcategory of evaluation and management codes would be selected for the visit to Dr. Parker? A.Office visit, new patient B.Office visit, established patient C.Outpatient consultation D.Case management services
Answer: C. Outpatient consultation Rationale: Dr. Smith requests Dr. Parker to see Mr. Andrews for a neurologic consultation. Dr. Parker evaluates the patient and provides a written report to Dr. Smith with a recommendation. The requirements for a consultation have been met and an evaluation and management code from outpatient consultation would be selected.
Physical Exam: General/Constitutional: No apparent distress. Well nourished and well developed. Ears: TMs gray. Landmarks normal. Positive light reflex. Nose/Throat: Nose and throat clear; palate intact; no lesions. Lymphatic: No palpable cervical, supraclavicular, or axillary adenopathy. Respiratory: Normal to inspection. Lungs clear to auscultation. Cardiovascular: RRR without murmurs. Abdomen: Non-distended, non-tender. Soft, no organomegaly, no masses. Integumentary: No unusual rashes or lesions. Musculoskeletal: Good strength; no deformities. Full ROM all extremities. Extremities: Extremities appear normal. What is the level of exam? A.Problem focused B.Expanded problem focused C.Detailed D.Comprehensive
Answer: D. Comprehensive Rationale: Organ Systems: Constitutional, ENMT, Lymphatic, Respiratory, Cardiovascular, Gastrointestinal, Skin, Musculoskeletal. There are eight organ systems examined. The level of exam is Comprehensive.
Subsequent Hospital Visit Labs: BUN 56, creatinine 2.1, K 5.2, HGB 12. Impression: 1.Severe exacerbation of CHF 2.Poorly controlled HTN 3.Worsening ARF due to cardio-renal syndrome Plan: 1.Increase BUMEX to 2 mg IV Q6. 2.Give 500 mg IV DIURIL times one. 3.Re-check usual labs in a.m. Total time: 20 minutes. What is the level of medical decision making? A.Straightforward B.Low C.Moderate D.High
Answer: D. High Rationale: Three problems worsening (six points); labs reviewed (one point); chronic illnesses posing a threat to life (exacerbation of congestive heart failure, poorly controlled hypertension, worsening acute renal failure due to cardio-renal syndrome). The medical decision making is High.
A new patient is seen in the ED by the pediatrician for severe ear pain. The patient has had pain for four days and it keeps her awake at night. She has had a slight fever (100.7°F). She has not been swimming or actively in water for the past couple of months. She denies any cough, nasal congestion or stuffiness, or loss of weight. The provider does a limited exam on the ears, nose, throat, and neck. The patient is determined to have otitis media. Amoxicillin is prescribed. What is the correct E/M code reported for this visit? A.99282 B.99283 C.99284 D.99285
Answer: B. 99283 Rationale: For an emergency visit, all three key components must be met: History—HPI (Extended), ROS (Extended), PFSH (none) = EPF Exam—Expanded problem focused (limited exam of ears, nose, throat, and neck) MDM—Moderate for the prescription drug management The documentation supports 99283
A patient is admitted to the hospital for a lung transplant. The admitting physician performs a comprehensive history, a comprehensive exam, and a high level of medical decision making. What is the appropriate E/M code for this visit? A.99221 B.99222 C.99223 D.99234
Answer: C. 99223 Rationale: Initial hospital care codes require all three key components be met to determine a level of visit. In this case, the comprehensive history and exam, and the high level of medical decision making support a 99223.
Physical Exam: Constitutional: Vital Signs: Pulse: 161. Resp: 30. Temp: 102.4. Oxygen saturation 90 percent General Appearance: The patient reveals profound intellectual disability. Tracheostomy is in place. Eyes: Conjunctivae are slightly anemic. ENT: Oral mucosa is dry. Neck: The neck is supple, and the trachea is midline. Range of motion is normal. There are no masses, crepitus, or tenderness of the neck. The thyroid gland has no appreciable goiter. Respiratory: The lungs reveal transmitted upper airway signs and bilateral rales, wheezes, and rhonchi. Cardiovascular: The chest wall is normal in appearance. Regular rate and rhythm. No murmurs, rubs, or gallops are noted. There is no significant edema to the lower extremities. Gastrointestinal: The abdomen is soft and nondistended. There is no tenderness, rebound, or guarding noted. There are no masses. No organomegaly is appreciated. Skin: The skin is pale and slightly diaphoretic. Neurologic: Cranial nerves appear intact. The patient moves all four extremities symmetrically. No lateralizing signs are noted. Gross sensation is intact to all extremities. Lymphatic: There are no palpable pathologic lymph nodes in the neck or axilla. Musculoskeletal: Gait and station are normal. Strength and tone to the upper and lower extremities are normal for age with no evidence of atrophy. There is no cyanosis, clubbing, or edema to the digits. What is the level of exam? A.Problem focused B.Expanded problem focused C.Detailed D.Comprehensive
Answer: D. Comprehensive Rationale: Organ Systems: Constitutional, Eyes, ENMT, Respiratory, Cardiovascular, Gastrointestinal, Integumentary, Neurologic, Lymphatic, Musculoskeletal. Ten organ systems were examined. The level of exam is Comprehensive.
Patient is seen in the ED for a migraine. She is experiencing nausea with vomiting and decreased appetite. Blurry vision. Has had a low-grade fever. The pain is rated 9 out of 10 and is not responding to oral medication. Physical exam: General appearance: Mild distress. 99.6 BP 110/60 Resp 18 Skin: Warm. Dry. No pallor. No rash. Good skin turgor. Facial: No bruises, no swelling, no tenderness. Scalp: No swelling, no deformity, no tenderness. Neck: Trachea midline. Cognitive function: Within normal limits. Best response: Within normal limits. Speech: Within normal limits. Sensation: Within normal limits. Motor strength: Within normal limits. Extinction-neglect: Negative. Reflexes: Within normal limits. Cerebellar test: Within normal limits. Assessment: Migraine headache - intractable, R/O viral infection, meningitis Plan: She will be admitted. Order CT of head and lumbar puncture. What E/M code is reported? A.99282 B.99283 C.99284 D.99285
Answer: B. 99283 Rationale: For an emergency visit, all three key components must be met: History—HPI (Brief), ROS (Extended), PFSH (none) = Expanded Problem Focused Exam—Detailed (extended exam of constitutional, skin, neck, neurologic) MDM—Moderate for (new problem to examiner with no additional work-up; order of radiology test (1 point); level of risk moderate [lumbar puncture] The documentation supports 99283.
IMPRESSION: Right recurrent gynecomastia. PLAN: The patient is sent for consultation re: right breast ultrasound initially performed by her primary care physician (PCP). The PCP requests a consultation for a gynecologist to recommend treatment. The gynecologist reviews the films showing a hypoechoic area measuring 1.7 x 0.7 x 1.2 cm in the 11 o'clock position of the right breast. There was no Doppler flow, and the transmission suggested that this was a cystic lesion. Because of this ultrasound and because this is symptomatic, I have recommended a simple mastectomy under general anesthesia. The patient agrees. I described the operation to the patient. What is the level of medical decision making? A.Straightforward B.Low C.Moderate D.High
Answer: B. Low Rationale: Established problem worsening (two points); ultrasound reviewed (one point); moderate level of risk (simple mastectomy). The medical decision making is Low
ESTABLISHED PATIENT OFFICE VISIT HISTORY OF PRESENT ILLNESS: Patient follows up today after a CT scan of her abdomen for abdominal pain. She continues to have the same symptoms that she was having at her last clinic visit. I have interpreted the CT scan and went over the images with her. The only very subtle abnormality in her right inguinal region is that of a slight bowing of her transversalis fascia. Otherwise, I do not notice any abnormality. Trying to correlate this with where her symptoms are located on her abdominal wall, these are in two separate locations. Her abdominal wall pain is approximately 3 cm above her inguinal canal. ASSESSMENT/PLAN: She will continue to hold off on any significant core activities. I have told her to try and avoid activities that reproduce her pain. If this is an abdominal wall injury, it is going to take several weeks for it to heal and she will need to hold off on those activities for the next six to eight weeks. She will contact my office in three weeks to let me know how she is doing with her conservative management. If she continues to have symptoms at that time, then she may require an MRI scan of her abdomen and pelvis to try and identify an etiology for her pain. What E/M code is reported? A.99212 B.99213 C.99214 D.99215
Answer: C. 99214 Rationale: New Patient Number and Complexity of Problems - One undiagnosed new problem with uncertain prognosis - Moderate Amount and/or Complexity of Data to be Reviewed and Analyzed - Independent interpretation of tests - Moderate Risk - Rest - minimal MDM
ESTABLISHED PATIENT OFFICE VISIT HISTORY: This is a 28-year-old lady who presents today for follow up. She went to the emergency room for lower abdominal pain on 03/24/X1. Urine pregnancy test was negative. Her last menstrual period was on 02/24/X1. She has not had a period. She is using condoms for contraception. She quit taking birth control pills in February. She also has slight vaginal discharge. She is para 1+3, had two miscarriages and one abortion in the past. She had a Pap smear in January of this year and it showed abnormal atypical squamous cells, ASCUS. She also had an HIV test which was negative. PHYSICAL EXAMINATION: No acute distress. Vital signs: Stable. No pallor. Chest: Clear. Heart: No murmur. Abdomen: Soft. Pelvic examination: Minimal vaginal discharge. Uterus is normal size and mobile. Positive slight adnexal tenderness. ASSESSMENT/PLAN: I have ordered urine pregnancy test, UA, and also GC/chlamydia were obtained. I have arranged pelvic ultrasound to rule out ovarian cyst. It seems that she may have pelvic inflammatory disease. I have given her Rocephin 500 mg in the office, followed by azithromycin two a day for three days, GC/chlamydia result, UA and pregnancy test, and we will re-evaluate after this. What E/M code is reported? A.99212 B.99213 C.99214 D.99215
Answer: C. 99214 Rationale: New Patient Number and Complexity of Problems - Undiagnosed new problem with uncertain prognosis - Moderate Amount and/or Complexity of Data to be Reviewed and Analyzed - 4 labs and 1 US - Moderate Risk - injection of antibiotic and prescription drug management - Moderate
Mrs. Standerfer's family physician visits her in the nursing home after a spell of dizziness and confusion reported by the staff at the nursing home. She sat down after lunch and stated she was dizzy. She slept for two hours after the spell. She states she is doing much better now. She has a known history of electrolyte imbalance and is on fluid restriction at the nursing home. She has not experienced any chest pain, dyspnea, unexplained weight changes, or intolerance to heat or cold. No complaints of head or neck pain. During the exam, the physician takes her BP both supine and standing, and notes her pulse and temperature. A detailed exam of the eyes, ears, nose, and throat is performed along with a detailed neurological exam. The physician orders blood work to determine if her electrolytes are out of balance again. What is the appropriate E/M code for this visit? A.99307 B.99308 C.99309 D.99310
Answer: C. 99309 Rationale: For subsequent nursing facility care codes, two of three key components must be met. History—(Extended), ROS (Extended), PFSH (1-Pertinent) = Detailed Exam—Detailed exam of eyes, ENT, Neuro MDM—New problem with additional workup, lab ordered, moderate risk (undiagnosed new problem with uncertain prognosis) = moderate medical decision making The documentation supports 99309
A patient is seen in consultation by endocrinologist at the request of her PCP for uncontrolled DM2. HPI: DM is uncontrolled. Recent A1C was 8.5. She is on oral meds. She has had eye exam two months ago. Her wellness exam was three months ago. She is under a lot of stress. No other new problems or complaints. HTN is controlled. Constitutional: WDWN female Heart: RRR, no edema Respiratory: Clear to auscultation Extremities: Normal pedal pulses, no edema A/P: DM type 2 uncontrolled, essential hypertension Plan for A1C before next visit. Return to office in three months for follow up. If A1C is still high, we will consider insulin. What is the level of medical decision making? A.Straightforward B.Low C.Moderate D.High
Answer: C. Moderate Rationale: The patient is in for follow up of chronic conditions. The conditions are both established. Diabetes is worsening (2 points) and the hypertension is stable (1 point). There is no data reviews and moderate risk (one or more chronic illnesses with mild exacerbation, progression, or side effects of treatment). Medical decision making is Moderate.
Hospital visit Chief Complaint: Gallstones and reflux. History of Present Illness: This is a 61-year-old woman who was seen in the ER and subsequently admitted in observation status. She has a two-year history of severe gallbladder attacks. Also, of note, she has had ongoing reflux problems for many years. Within the last few months, her reflux has worsened. Assessment/Plan: This is a 61-year-old woman with symptomatic cholelithiasis and reflux. Her number one concern right now is the gallbladder pain. This sounds like symptomatic cholelithiasis. As a result, we will schedule her for laparoscopic cholecystectomy with intraoperative cholangiogram. The risks and benefits were explained to the patient who understood and agrees for us to proceed. With regard to her reflux, it is partially controlled by her medication. She also is overweight and might have symptom improvement after weight loss. She is also very hesitant to proceed with the Nissan fundoplication because her husband had the surgery done before and had some problems with vomiting afterward. She does have objective evidence of reflux as well and is a good candidate for surgery. However, we will let her decide whether she wants to proceed with this procedure. What is the level of medical decision making? A.Straightforward B.Low C.Moderate D.High
Answer: C. Moderate Rationale: Two problems worsening (four points). No data reviewed with moderate level of risk (elective major surgery). The medical decision making is Moderate.
ED Visit: Data: BUN 74, creatinine 8.8, K 4.9, HGB 10.8, Troponin 0.01. I reviewed the EKG which shows some LVH but no ST changes. I also reviewed the chest X-ray, which showed moderate pulmonary vascular congestion, but no infiltrate. Impression: New problem of pulmonary edema due to hypervolemia. No evidence of acute MI or unstable angina. The patient also has ESRD, which is stable, and poorly controlled HTN, which is most likely due to hypervolemia. Plan: I spoke with the dialysis unit. We can get him in for an early treatment this afternoon as opposed to having to wait for his usual shift tomorrow. For that reason, it is okay to discharge him from the ED to go directly to the unit. What is the level of medical decision making? A.Straightforward B.Low C.Moderate D.High
Answer: D. High Rationale: New problem to examiner, additional workup: dialysis (four points); Labs, EKG, and X-ray reviewed (three points); high level of risk (chronic illness posing a threat to life). The medical decision making is High.
