Chapter 15: Step-by-Step

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Medical Insurance Billing and Coding

A patient who was on observation status for 48 hours is discharged from the hospital. The patient was being observed after a motor vehicle accident for subdural hematoma, which was subsequently ruled out. Code only the discharge services and diagnosis.

CPT Code: ________.

99217

A 16-year-old female is being admitted by her family practice physician with a 2-week history of fatigue and fever. It has been progressively getting worse. She is suffering from dehydration. The physician performs a comprehensive history to look for explanations for her fatigue, including recent activity level and recent sleep habits. A detailed examination is performed and she is diagnosed with mononucleosis and admitted for treatment.

CPT Code: ________.

99221

The 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 joint 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: ________.

99214

The 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: ________.

99201

A 38-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 injury. During the comprehensive examination the patient's gait and movement were observed. Moderate-complexity decision making is performed, including different treatment options. A separate note is dictated to show the requesting physician what results were found during the visit, and the decision on treatment of her pain.

CPT Code: ________.

99244

A 46-year-old male is admitted to the hospital with a progressive staphylococcal pneumonia that is not responding to treatment. A request is made for the infectious disease physician on staff to render his opinion for treatment. The patient is seen in initial inpatient consultation. An expanded problem focused history and examination are performed. After looking at the sputum cultures, the physician decides on the most effective antibiotic for treatment. The decision making is straightforward.

CPT Code: ________.

99252

A 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 a year 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: ________.

99242

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.

CPT Code: ________.

99251

A 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 infant's parents. It was determined that the patient does attend a day care facility, and that the cough and fever have been present for approximately 5 days. In addition, it is learned that the infant started having trouble breathing this morning. The patient is intubated. Pneumonia due to respiratory syncytial virus is the definitive diagnosis. A comprehensive examination is performed along with moderate decision making. More tests will follow. A copy of his dictation will be sent to the primary physician.

CPT Code: ________.

99254

A patient presents to the emergency department after being involved in a motor vehicle accident. The patient was wearing a seat belt; however, 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: ________.

99285

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: ________.

99318

Subsequent follow-up care is provided for the 82-year-old male nursing facility patient with Alzheimer's disease. The resident has responded well to some new medications and appears to have recovered some of his cognitive abilities without behavioral disturbances. The physician performs a problem focused history and physical examination on his neurological problem and orders the current treatments continued. The MDM complexity is low.

CPT Code: ________.

99307

The physician provides services to a resident of a rest home for an ulcerative sore on the heel and midfoot. Given the fact that the patient is in reasonably good health and is not diabetic, the physician focuses his attention on the right lower extremity during the problem focused physical examination. The physician knows the resident well and performs a brief HPI and ROS during a problem focused history. The resident thinks the sore is from new shoes, and the physician agrees with that conclusion. Topical antibiotic cream is ordered, and the new shoes are sent to be stretched. The MDM complexity is straightforward.

CPT Code: ________.

99334

An established patient is seen in the office 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: ________.

99215 for the office visit (Office and/or Other Outpatient Services, Established Patient) and 99354 and 99355_2 for the Prolonged Services (Prolonged Services).

99215 is for the 40 minutes of initial office service, and 99354 and 99355 are for the additional 110 minutes.

A 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: ________.

99396

A new 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 pharyngitis and straightforward decision making was performed. Amoxicillin was prescribed.

CPT Code: ________.

99202

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: ________.

99238

A physician visits a 75-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 plan 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: ________.

99318

Henry Green, an established patient, came into the office for his yearly physical examination. Henry is 72 and in good health.

CPT Code: ________.

99397

The patient is a 78-year-old female whom we have been following in our clinic for hypertension and also chronic pudendal nerve pain. She had been recently diagnosed with pelvic metastatic clear cell carcinoma which her primary location is unknown at this time. She will be discussing this further after the pathology reports are read. During her hospital stay a Hickman catheter was placed in order to have IV access for pain medication or future cancer therapy. She was also admitted for chronic pain. She did develop swelling of her arms and neck. She was brought to interventional radiology and she did have venography and the Hickman catheter was removed. The swelling to her arms and neck have decreased greatly. She denies any shortness of breath.
Total time spent with the patient today is 60 minutes.



CPT Code: ________.

99239

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