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Chapter 15, "Evaluation and Management (E/M) Services," pages 431-496

CHART NOTE

CC: This established patient presents to the office today with complaints of rectal bleeding and itching of 2 weeks' duration.

OBJECTIVE: This is a 50-year-old male in apparent good health. His BP is 119/78. Rectal examination showed a Grade I hemorrhoid in the 2 o'clock position approximately 2 cm across. The area around the hemorrhoid was slightly inflamed and a small amount of blood was noted.

ASSESSMENT: Hemorrhoid.

PLAN: Discussed conservative treatment options with the patient and explained surgical option. He wants to try the more conservative approach of stool softeners, warm and sitz baths. I discussed with him the importance of improved bowel habits. He is to return for a recheck in 2 months. The medical decision making was of straightforward complexity.

CPT Code:

CPT CODE 99212

DIALYSIS PROGRESS NOTE

LOCATION: Inpatient, Hospital

PATIENT: Gloria Baxter

ATTENDING PHYSICIAN: Ronald Green, MD

This patient is continuing on CAPD. Her weight has fluctuated to some extent dependent on some GI losses. She has not been ultrainfiltrating aggressively, but she has not been eating well either. Over the last day or so she has had problems with hypotension, related to perhaps initially bradycardia and then subsequently to recurrence of atrial fibrillation with a more rapid rate. She did drop her weight to 154, and we have given her some saline boluses through the night. This morning she is reasonably stable. Her weight is 158 pounds. She has no congestive failure and no pain. Her abdomen is soft. Fluid clear. Cultures have remained negative. She had been on Unasyn coverage because of an elevated white count and suspected sepsis but that has not materialized.

The management plan at this time is to discuss a different drug management plan with cardiology to see whether or not she is a candidate for a class III drug in view of the patient's intolerance to digoxin and/or quinidine. She may well tolerate digoxin at a lower dose, but the problem is it is not effectively blocking her ventricular response.

The other component of her management will be to interrupt the antibiotic and observe her, and then thirdly she will get esophagogastroduodenoscopy today and a CT of her abdomen tomorrow to try to investigate the true core problem that she has. Finally, we are going to increase her Epogen slightly to try to push her hemoglobin up a little faster and try to keep her over 12. This will be a substitute for her hypoalbuminemia and hopefully will maintain her blood pressure and her organ perfusion a little bit better.

This illness is still serious. She is not thriving. She is not eating well, and her prognosis at this point is still extremely guarded. Code level II reaffirmed. (MDM is high complexity.)

CPT Code

99233

This patient is seen in the clinic at the request of Dr. Jones for evaluation of suprapubic pain. Patient is a 22-year-old black female G1 P0, LMP 12/20/xx, EDC 10/16/xx by 14-week ultrasound taken on 4/16/xx, 18 weeks with twin gestation. Presents with complaint of suprapubic sharp to mild pain with onset 2 months ago. Pain has become progressively worse. Patient has been seen by Dr. Jones for this pregnancy and has also been seen by Dr. Smith for this current complaint 2 weeks ago. Patient denies urgency and frequency of nocturia, denies hematuria, and denies discharge.
Labs: CBC and urinalysis performed.
Allergies: none. Past medical history: genital wart 1986.
Past surgical history: wart removed by laser 1986.
Social history: no smoking, illicit drugs, or alcohol.

PE: During an expanded problem-focused examination, the HEENT was found to be normal.
FHT: A 148, B 146.
Heart: normal.
Lungs: CTA.
Abdomen: gravid 20 cm. Slight tender suprapubic region.
Vaginal exam: closed cervix, thick, long; no discharge.
Extremities: negative for edema; UA loaded with bacteria and WBC.
Impression: 1. IUP at 18 weeks with twin gestation. 2. Acute UTI (the MDM was straightforward).

Recommendation: Keflex, 500 mg, and follow-up with Dr. Jones

99242

4. The level of E/M service is based on:
Documentation
Key components
Contributing factors
All of the above

all of the above

According to E/M guidelines, a(n) ________ exam encompasses a complete single-specialty exam or a complete multisystem exam.
Problem-focused
Expanded problem focused
Detailed
Comprehensive

Comprehensive

What are the four levels of medical decision making complexity?

Low Complexity High Complexity Moderate Complexity Straightforward

The code range for Home Services is ________.

99341-99350

What are the four levels of history type?

problem-focused, expanded problem-focused, detailed, comprehensive

What CPT code is assigned to an ED service that has a detailed history and exam with a moderate level of MDM?99284
99291
99283
99220

99284

Mr. Smith presents to the Emergency Department at the local hospital for chest pain and is seen by the ED physician on duty. The physician obtains an extended HPI, an extended ROS, and a pertinent PFSH. What is the level of history? Problem-focused
Expanded problem focused
Detailed
Comprehensive

detailed

An initial inpatient consultation with a detailed history, detailed exam and MDM of low complexity

99253

The physician performs an extended exam of the affected body areas and related organ systems. What is the level of the examination?
Problem-focused
Expanded problem focused
Detailed
Comprehensive

detailed

Dr. Martin provided 1 hour and 20 minutes of critical care services to Jack Smithton (age 64), who is in the Intensive Care Unit with acute respiratory distress syndrome. (Separate the codes with a comma in your response as follows: XXXXX, XXXXX.)

99291, 99292

Counseling, coordination of care, nature of presenting problem, and time are considered:
Levels of E/M service
Key components
Contributory factors
Medical decision-making process

Contributory factors

These elements would be part of the ________ history: employment, education, use of drugs.
Past
Social
Family
Any of above

Social

The HPI must be documented in the medical record by:
The physician
Any office staff member
The patient
Any of the above

The physician

When a physician performs a preventive care service, the extent of the exam is determined by the:
Age
Gender
Gender and age
Length of time elapsed since last exam

Age

The definition of low birth weight can be found in the notes for subheading ________.

Continuing intensive care

LOCATION: Emergency Room

SUBJECTIVE: This is a 38-year-old female who presents to the emergency room with a history of currently being under treatment for a right corneal abrasion that occurred on Sunday. She states she was seen by the "eye doctor earlier today" and now has a bandage over her eye. Apparently her eye is opened underneath the bandage and she is unable to close her eyelid. She feels her eyelid is stuck to the bandage.

OBJECTIVE: She is afebrile with stable vital signs. The patch was removed and there was a folded piece of Telfa that had slipped down and her upper eyelid was unable to close over the top of this. The Telfa was removed and a wet patch was placed. This did provide significant comfort. Her eye patch was reinforced.

ASSESSMENT: 1. Right corneal abrasion under treatment. 2. Eye patch replaced as described above.

PLAN: She has a follow up visit tomorrow morning with ophthalmology. I told her she needs to keep that appointment. She is to return here sooner if she is having increasing problems.

CPT Code:

99281

The term used to describe a patient who has NOT been formally admitted to a health care facility is ________.

outpatient

The ________ is a statement describing the reason for the encounter and is a history element.

Chief Complaint

Modifier ________ is used to indicate that a separately identifiable E/M service was performed by the physician on the same day as the preventive medicine service.

-25

Donald Mayors is a homebound patient who is experiencing some new problems with managing his diabetes. Dr. Martin, who has never seen this patient before, drives to Donald's residence and spends 20 minutes examining the patient and explaining the adjustments that are to be made in the insulin dosage. The medical decision making is straightforward.

CPT Code:

99341

CHART NOTE

CC: Dizziness

SUBJECTIVE: This 46-year-old female established patient presents today reporting feeling ill yesterday, and she has developed some dizziness. She feels like things stick in her throat and that her throat is "sticky." She has a past history of hypothyroidism and taking Synthroid 0.125 mg q day. Her last TSH was last year and the level appeared to be normal at 0.49.

OBJECTIVE: The patient appears to be in good health and in good spirits. Her BP is 120/81. Afebrile. HEENT normal. Neck is supple. No palpable masses are noted. No thyromegaly, tenderness, or nodes. TSA is elevated at 9.9.

ASSESSMENT: Hypothyroidism (MDM was low).

PLAN: Increase Synthroid to 0.15 mg q day. Recheck in 2 months.

CPT Code:

99213

CAPD CYCLER DIALYSIS PROGRESS NOTE

LOCATION: Inpatient, Hospital

PATIENT: Mandy Horton

ATTENDING PHYSICIAN: Ronald Green, MD

This patient was reasonably stable overnight. She was evaluated empty . She was in no cardiorespiratory distress. Clear lungs, dullness at the bases. A few crackles but otherwise a somewhat irregular heart rhythm this morning. Echocardiogram pending. Abdomen soft. Exit site okay. She was going to be put on CAPD today. This is being done to facilitate some of her studies as we can work this around them. CT is planned for this morning. The CT will be a critical study since we do have significantly abnormal liver function and the question is what could be possibly going on there. She has an esophagitis consistent with herpes or CMV, and the situation could turn ominous depending on the CT results. We are also doing a calorie count to see whether or not we need to consider supplementing her if everything else works out.

The dialysis plan today will be to use five 2.5-liter exchanges, three of them being 2.5% and two of them 1.5%. (MDM is moderate complexity.)

CPT Code:

99232

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