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Medical Coding

Assign the appropriate Evaluation and Management code for a home service visit for the following exercise. Do not code the diabetes.

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.

99341 Hint: Evaluation and Management, Home Services

Assign the appropriate Evaluation and Management code for an office visit for the following exercise.

A 40-year-old established patient presents to the physician office for a preventive care exam.

99396 Hint: Evaluation and Management, Preventive Services

Assign the appropriate Evaluation and Management code for a newborn care service visit for the following exercise.

History and exam of the normal newborn infant born in a hospital setting.

99460 Hint: Evaluation and Management, Newborn Care

The code range for Home Services is ____________________. (Use a hyphen to separate the codes. Do not include extra spaces.)

99341-99350 Hint: Evaluation and Management, Home Services

Assign the appropriate Evaluation and Management consultation code for the following exercise.

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

99253 Hint: Evaluation and Management, Consultation

Assign the appropriate Evaluation and Management code for an office visit for the following exercise. Do not code the diagnosis or treatment.

A 7-year-old female established patient presents to the pediatrician complaining of ear pain x 3 days. A detailed history is then taken. She had associated fever of 101ºF yesterday. Mom treated her with Tylenol. The fever this AM is 99ºF. She has had some chills and cough as well as some difficulty breathing. No nausea or vomiting. No prior history of Otitis. Brother was sick earlier this week. The physician performed a detailed exam of the ENT as well as a limited exam of GI, Lungs, and Heart. Vital signs were taken in the office. The physician diagnosed the patient with Otitis Media and an Upper Respiratory Infection and prescribed an antibiotic. The MDM is stated to be moderate.

99214 Hint: Evaluation and Management, Office and Other Outpatient

Assign the appropriate Evaluation and Management codes for critical care services for the following exercise. Do not include 'X1' or 'X2' with the codes. Do not code the diagnosis.

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. Do not code the diagnosis.

99291, 99292
Hint: Evaluation and Management, Critical Care

Assign the appropriate Evaluation and Management code for an office visit for the following exercise.

A new patient presents to the physician's office at which time the physician provides a comprehensive history and exam with a high complexity MDM.

99205 Hint: Evaluation and Management, Office or Other Outpatient Services

Assign the appropriate Evaluation and Management code for an office visit for the following exercise. Do not code the diagnosis or the referral to Dr. Andrews.

This is a 15-year-old girl, never seen at this clinic. During a problem-focused history, she states that she noticed a lump on the back of her right wrist yesterday.

Physical Examination: There is a 2-cm freely movable, rubbery, round swelling on the dorsal surface of the right wrist. Distal neurovascular and tendon exam intact. This is not painful to palpation. (The MDM was of straightforward complexity.)

Impression: Ganglion cyst, right wrist.

Treatment: Refer to Dr. Andrews for further treatment.

99201 Hint: Evaluation and Management, Office or Other Outpatient Services

Assign the appropriate Evaluation and Management code for an office visit for the following exercise. Do not code the diagnosis or treatment.

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.

99213 Hint: Evaluation and Management, Office and Other Outpatient

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