Chapter 17 - Evaluation & Management - Review Questions

99382-25, 90471, 90710

A 2 year-old comes in for an initial WCE. Mom doesn't have the child's immunization record. She states the child's last shot was when he was 5 months old. Medical review and documentation of a new patient supports one element of HPI, five elements of the ROS, and a complete PFSH. The examination was 8+ organ systems. The physician orders the immunizations to be given in the office today. Immunizations given subcutaneously: MMRV. What CPT codes are reported?

99285

A 25 year-old male is brought in by the EMS to the ER for nausea and vomiting. The patient has elevated blood sugars per EMS. EMS and the physician are unable to get a history due to patient's altered mental status. The ED physician performed a comprehensive eight organ system exam and a high level MDM. Patient was transferred to ICU in stable condition. Total critical care time 25 minutes. What CPT code is reported?

99238

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

99348

A physician makes a home care visit on a 63 year-old patient that is a hemiplegic having insomnia for the last two weeks. The patient has been home bound for the last year. The last visit from this physician was four months ago to control his DM. The physician performs an expanded problem-focused examination and low MDM. The physician then speaks with the spouse about the possibility of placing the patient in a nursing facility. What CPT code is reported?

99214

An established 45 year-old woman is seen today at her doctor's office. She is complaining of being dizzy and feels like the room is spinning. She has had palpitations on and off for the past 12 months. She reports chest tightness and dyspnea but denies nausea, edema, or arm pain. She drinks two cups of coffee per day. Her sister has WPW (Wolfe_Parkinson-White) syndrome. An extended five body area examination is performed. This is a new problem for the physician. An EKG is ordered and labs are drawn, and physician documents a moderate complexity MDM. What CPT® code is reported for this visit?

99202-25, 73562-LT, M17.9

Chief Complaint: Left knee pain. HPI: A 67 year-old female is seen today as a new patient with left knee pain for approximately one month. She offers a catching sensation. Pain is primarily through the medial joint line. There is no significant instability, Pain is worse in the morning and right before she goes to bed. She is currently taking Celebrex which helps alleviate the pain. She offers prior history of automobile accident in the 1980s. She is currently not performing any home exercises, nor has she undergone any recent injections. Current Medications: Metformin, metoprolol, Lipitor, glipizide, Synthroid, Altace, ranitidine, Celebrex. Allergies: Sulfa, penicillin, and IVP dye. Past Medical History: Significant for hypertension, diabetes, thyroid disorder, previous history of a stroke, cardiac disease. ROS: She currently denies any unstable angina, no pulmonary disorders or productive coughs. No history „, renal dysfunction. Denies gastric ulcer. She was without any unexpected weight loss or constitutional signs „I infection. She has no known coagulopathies. Social History: She denies tobacco and alcohol use. She is retired. Family History: Diabetes, heart disease, and cancer. Physical Examination: She has pronounced retropatellar crepitation. There is bogginess of the synovium, tenderness through the medial joint line. Ligamentous evaluation is stable. She has varus alignment of the knee. She is intact to sensation, has palpable pulses. Ancillary Studies: AP, lateral and sunrise views ordered and interpreted today, May 3, 20xx. They reveal calcification within the vascular structures. There is decreased joint space through the medial compartment where she has near bone-on-bone contact, flattening of the femoral condyles, no fractures noted. Impression: Left knee pain secondary to underlying degenerative arthritis. Plan: We will proceed with a course of joint lubrication therapy and physical therapy. Injection series has been ordered. In the interim, she may continue activities as comfort allows, limiting repetitive stair climbing and kneeling. What are the CPT and diagnoses codes to report?

99242, N39.0, R32

History and Physical Patient: SP Date: 2/4/xx Referring Physician: SK, M.D. Chief Complaint: Chronic UTIs HPI: Ms. P is a 29 year-old young lady referred to us by Dr. K for evaluation of the above. She states that she underwent a C-section in 20xx. This was complicated by a reaction to the epidural as well as a post-op hematoma. It has resulted in decreased sensation of her bladder filling. She has had some predominant urge incontinence and urgency for the past few months, which was preceded by a stress incontinence that she has not been treated for. This has also resulted in a UTI about once a month. She seemed to be doing timed voiding on her own to decrease the amount of urine and to have fewer accidents. She says she has good stream when she voids. She feels like she does not completely empty. She has had no dysuria, frequency, or hematuria, but does have nocturia three times a night. Thus Dr. K referred her to us for evaluation of the frequent infections and urinary incontinence. She has no history of stones, sexually transmitted disease, or family history of any urologic problems Past Medical History: Significant for depression Past Surgical History: Tonsillectomy, adenoidectomy, C-section, and myringotomy tubes Medications: Zoloft Allergies: STADOL, MORPHINE, LATEX, RELPAX Social History: She is married and is a medical assistant at Max's Dermatology. She does not smoke. Drinks occasionally. No history of alcohol abuse. Exercises regularly. Family History: Significant for hypertension. Physical Exam: Constitutional: Well-nourished, well-developed white female who looks her stated age, in no acute distress, pleasant, and cooperative. HEENT: Within normal limits Neck: Supple, no masses. Respiratory: Clear to auscultation. Cardiovascular: Regular rate and rhythm. GI: Abdomen is mildly obese, benign with active bowel sounds throughout; no hepatosplenomegaly. No CVA tenderness, back without deformity. Extremities: No clubbing, cyanosis, or edema. Neurological: Nonfocal. Genitourinary: Pelvic support normal. Vagina normal in appearance. No vulvar irritation or discharge. Labs: Urinalysis specific gravity 1.010, pH 5, otherwise negative. PVR of 60 cc. Assessment/Plan: We will have her obtain a MESA symptom score, voiding diary, and a local cystourethroscopy. We will obtain her records from Dr. M. for further evaluation and review. DB, M.D., F.A.C.S Urology Board Certified Urologist February 4, 20xx SK, M.D. 29 Mountain Trail Colorado Springs, CO 29192 Dear Dr. K: I appreciate your asking me to evaluate SP for her chronic UTIs and urinary incontinence. She was seen today in my office, A brief summary and recommendations are as follows: We will have her undergo some routine testing including a cystourethroscopy. We will obtain her records from her gynecologist and make further recommendations at that time. Thank you again for your kind referral. I appreciate your gesture and will keep you updated regarding her urological progress. Sincerely, DB, M.D., F.A.C.S. What are CPT and diagnosis codes to report?

99231

The physician was notified to go to the hospital floor for medical management of a 56 year-old patient admitted one day ago for aspiration pneumonia and COPD. No chest pain at present, but still SOB and some swelling in his lower extremities. He was tachypneic yesterday; lungs reveal course crackles' in both bases, right worse than left. He is continuing with intravenous antibiotic treatment and respiratory support, reviewed chest X-ray and labs. The patient is improving and a pulmonary consultation has been requested. What CPT code should be reported?

The upper central region of the abdomen

When a patient complains of epigastric pain. Where is the pain located?

Musculoskeletal

Which system is given credit in the exam component when the provider documents "range of motion, strength, and stability are adequate in both legs?"