Unit2Homework.pdf

CHAPTER 15 r Evaiuation and Management (E/M) Services

,/fA, four types of medical decision making, in order of complexity from most to

List the fi least risk

,d--A- A- ,lr,

-lr-

Inpatient time spent at the bedside or nursing station during or after

the visit is what kind of time?

21. Thepatient's will reflect the . nrm-ber of systems examined by a brief statement of the findings.

/ZZ. I discussion with a patient andlor family concerning one or more of the following areas: diagnostic results, impressions and/or recommended diagnostic studies; prognosis; risks and benefits of treatment; instruciions for treatment; importance of compliance with treatment; risk factor reduction; and patient and family education is

23. The history is the physician.

information the Patient tells the

Ol4r11bcrd .rasvl-crs are located in Appendix B, while the full answer key ls only available in the TEACE

Iffir Ecsorrrces on Erolve.

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13. Complexity of medical decision making is based on three

ve types of presenting problems from the most risk and least recovery to

and most recovery:

19. Counseling and coordination of care are what kind of factors in most

cases?

U/O. ,r*"that is used as a guide for outpatient services is what kind of time?

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CHAI{ER 15 r Evaluation and Management (E/l[l Sersices

6n. ,n"re is no distinction made between the new and established patients

in this service department of a hospital:

25. Those services rendered by a physician whose opinion or advice is requested by another physician or agency in the evaluation and/or

treatment of a patient is a(n) whereas the physician who has primary responsibility for the patient in the hospital

is called

r'26. Whencritically ill patients in medical emergencies require the constant attendance of the physician (e.g., cardiac arrest, shock, bleeding, and respiratory failure) to stabilize them, what kind of care is needed?

27. When care is provided same patient by more

conditions, the care is

for similar services than one physician

(e.g., hospital visits) to the on the same day for different

,6. *nuris the name for the assumption of the total or speciflc care of a patient from one physician to another that does not constitute a

consultation?

29. An inventory of body systems obtained signs and/or symptoms that the patient

."{o. ,tthe physician who is standing by does so for 25 minutes, can he ot she round the time up to 30 minutes for reporting purposes?

through questioning to identifY may be experiencing is a(n)

of

Odd-numbered answers are located in Appendlx B, while the full answer key is only avaitrablc ir ft TEI'€E Instructor Resources on Evolve.

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CIL{PTER 15 r fyil*5on irnd Management (E/}vf) Services

PRACTICAT

Office or Other Outpatlent Services and Hospltal lnpatient Service With the use of the CPT and ICD-10-CM/ICD-9-CM manuals, camplete the following:

3\. Analyze this case in which the patient record states: 40-year-old male patient (new) is evaluated for contusion of a finger. The history and examination were problem focused.

a. Diagnosis and management options for contusion of finger. (Options can be minimal, limited, multiple, or extensive.) Diagnosis and

management options:

Data to review to provide service. (Data can be minimal/none, limited, moderate, or extensive.) Only data available are current

information obtained during the visit. Data:

b. Risks if left untreated. (Risk can be minimal,

Risks:

low, moderate, or high.)

c. All three of the elements have been met to qualify this patient for

what level of decision making complexity?

d. The patient record indicates that a problem focused history and examination were done. When this is combined with the level of decision-making complexity you arrived at for this patient, what is

for 48 hours is discharged from the hospital. The patient was being observed after a motor vehicle accident for subdural hematoma, subsequently ruled out. Code onty the discharge services and diagnosis.

CPT Code:

ICD-1O-CM Codes:

(ICD-9-CM Codes:

33. Initial observation of a patient was for upper abdominal pain, dizziness, and anemia. A comprehensive history and examination was performed. Moderate complexity decision making was conducted to admit the patient to observation to treat and rule out causes of the patient,s anemia.

CPT Code:

(nrnbcrcd arlsrYers are located in Appendix B, while the full answer key is only available ln the TEACH hltrrcfa fcrm,ccs oa Evolve.

the correct CPT code for the case? Code:

{32. A patient who was on observation status

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CHAPTER 15 r Evaluation a.n; \0nmw:3,

/74. A 16-year-old female is being admitted by her familr rorffir:u , with a 2-week history of fatigue and fever. It has b€en SW,'l* getting worse. She is suffering from dehydration. The F.xr.: - performs a comprehensive history to look for explanab;n: r"r fatigue, including recent activity level and recent sleep [:.a:m: detailed examination is performed and she is diagnosed -w: mononucleosis and admitted for treatment.

CPT Code:

ICD-10-CM Codes:

(lCD-9-CM Codes:

35. A 56-year-old male with an established history of ASHD of natire arteries and past stent placement is admitted through the emerger::*, room with acute onset of chest pain. An EKG was performed and troponin levels taken. Both showed evidence of the patient having a:: acute inferior wall myocardial infarction. The cardiologist performs a comprehensive history, with the chief complaint, 4 from the histon c: present illness (HPI), a complete review of systems (ROS), and past, family, and social history (PFSH). The history includes the information that the pain started a week ago but last night worsened. Also on a scale of 1 to 10, he rated the pain an 8. It was also discovered that the patient has not been attending regular appointments in the clinic setting. A comprehensive examination was performed along with high- complexity medical decision making (MDM), including management of the patient's acute MI and reviewing data of the medical history of the patient. He was taken immediately to the cardiac catheterization lab to look for the source for the patient's ML

CPT Code:

ICD-1O-CM Codes:

(ICD-9-CM Codes:

/36. Th"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 ioint 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:

ICD-10-CM Codes:

(ICD-9-CM Codes:

Odd'numbered answers are located in Appendix B, while the full answer key is only available in the TE-.\,CH Instructor Resources on Evolve.

Copyright @ 2015 by Saunders, an imprint of Elsevier inc. Al1 rights reserr.,ed.

:":--rJll} :: I

3;- -{ l!-yearold boy with bacterial pneumonia is ho5pitalized and has had 5 days of antibiotic therapy. Today the child developed a fever of 101' F rtith a mild rash on his tofso. In a subsequent hospital visit, the attending physician performed a problem focused history and examination. The MDM complexity was low.

CPT Code:

ICD-1O-CM Code:

(ICD-9-CM Code:

*46. fne 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:

ICD-10-CM Code:

(ICD-9-CM Code:

Consultation Services 39. A 47-year-old female was sent by her family practice physician for an

office consultation with a gynecologist. The patient has been suffering with moderate pelvic pain, a heavy sensation in her lower pelvis, and marked discomfort during sexual intercourse. In a detailed history, the gynecologist noted the location, severity, and duration of her pelvic pain and related symptoms. In the review of systems, the patient had positive findings related to her gastrointestinal, genitourinary, and endocrine body systems. The physician noted that her medical history was noncontributory to the present problem. The detailed physical examination centered on her gastrointestinal and genitourinary systems, with a complete pelvic examination. The physician ordered laboratory tests and a pelvic ultrasound to determine uterine fibroids, endometritis, or other internal gynecological pathology. The MDM complexity was moderate.

CPT Code:

ICD-10-CM Codes:

(ICD-9-CM Codes:

lO. A38-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 iniury. During the comprehensive examination the patient's gait and

Odd-numbered answers are located in Appendlx B, while the full answer key is only avallable in the TEACH Instructor Resources on Evolve.

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CHA?TER 15 r Evaluation arld \{anagement rBUt Senices

movement were obselved. Moderate-complexit-V decision maliing is

peformed, including different treatment options' A separate not€ is

di.tut"d to show thirequesting physician what results rt"ere found during the visit and the decision on treatment of her pain'

CPT Code:

ICD-10-CM Codes:

(ICD-9-CM Codes:

CPT Code:

CPT Code:

ICD-10-CM Code:

(ICD-9-CM Code:

41. An inpatient urological consultation is performed for a 3}-yearold female who recentiy had an elective abortion performed on an

outpatient basis. The woman has been admitted with a high fever, pelvic

pain, and dysuria. During a detailed history, the urologist notes in the irirtory of piesent illness that the patient's symptoms began abortt 2

days ifter ihe abortion and progressed to the acute phase, which she is in at the present time. The lbcation of the pain is in the lower abdomen and rated 9 on a scale of 1 to 10. She reports the quality of the pain to be sharp and stabbing. In the review of systems, the physician notes

positive responses in 5 of the L2 body systems investigated. The urologist notes a negative medical history related to urinary symptoms

other-than a mild.frtitl. about 10 years ago. The detailed physical examination performed by the urologist centels on the genitourinary

system and gistrointestinil system in significant detail..The medical decision making is low. Given the patient's past surgical procedure and

physical findinfs at the present, the consultant considers the diagnoses of pyelonephritis, cystitis, pyelitis, and endometritis'

',)

,d. O46-year-old male is admitted to the hospital with a progressive staptrylococcal pneumonia that is not responding to treatment' A

r"qr.it is made for the infectious disease physician on staff to render his opinion for treatment. The patient is seen in initial inpatient .onrrltation. An expanded problem focused history and examination are performed. Aftei looking at the sputum cultures, t{: PhYsician decides on the most effective antibiotic for treatment' The decision making is straightforward.

43. The initial consulting physician subsequently sees a Ss-year-old patient injured at work whei

-he"fell from a house roof and struck his head- The

patient had a right frontal parietal craniotomy 6 days previousll'and is

iecovering rapidly. The initial consultation was requested regarding a possible d-rug reactlon that produced a rash on the uppel torso. The-

consultant ricommended a medication change, but after 48 hours t1.e

patient had no improvement. The physician re-evaluates for other

possible causes of ifre rash. An expanded problem focused inten-al

Odd-numbered answers are located in Appendix B, while the full answer key is only available in th€ IEACE

Instrrrctor Resources on Evolve.

copyright @ 2015 by Saunders, an imprint of Elsevier Inc. A11 rights reserved.

CFL\PTER 15 r Evaluation and Management (E/M) Services

history and a physical examination were performed. The MDM complexity was moderate.

CPT Code:

ICD-10-CM Code:

(ICD-9-CM Code:

/++. l,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 ayear 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:

ICD-10-CM Code:

(ICD-9-CM Code:

45. This is a follow-up visit on a Z9-year-old male who is admitted with the diagnosis of headlches. The patient is subsequeptly seen because the physician needs to follow up on test results that weren't back yet at the initial consultation. This wiii help to find a possible cause of the headaches and course of treatment. A problem focused history and examination and low-complexity decision making is made after viewing the CT results. The diagnosis of tension headaches was made and treatment options discussed.

CPT Code:

ICD-10-CM Code:

(ICD-9-CM Code:

u/+0. 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.

Odd-numbered ansrf,ers are located in Appendix B, whlle the full answer key is onty available in the TEACII Instructor Resources on Evolve.

Copyright @ 2015 by Saunders, an impdnt of Elsevier Inc. All rights reserved.

CHAPIER 15 r Evaluation and Managem€rt rE]{i Strr-x:

CPT Code:

ICD-10-CM Code:

(ICD-9-CM Code:

47. Apatient is sent to a general surgeon by her family physician for an oplnion and recommendation for surgical repair of a recurrent femoral hernia, right. A brief problem focused history of present illness and a problem focused examination of the affected body area and organ system are performed in the office. The MDM complexity was straightforward.

CPT Code:

ICD-IO-CM Code:

(ICD-9-CM Code:

,r/+5. I 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

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

CPT Code:

ICD-10-CM Code:

(ICD-9-CM Code:

49. Office neurosurgery consultation is requested by the primary physician fot a 3Z-year-old man on workers' compensation who is unable to work because of displacement of intervertebral lumbar disc with myelopathy. TWo previous surgical repairs have been unsuccessful in relieving the patient's pain. The patient has been unable to return to his employmint as a bricklayer. He complains of radiating pain throughout the buttocks and leg, with numbness throughout the leg and foot. Reflexes are minimal to nonexistent. A comprehensive history and physical examination are performed. MDM complexity was high due to the prior surgeries and continued complaints.

CPT Code:

ICD-10-CM Code:

(ICD-9-CM Code:

Odd-numbered answers are Iocated in Appendix B, while the full answer key is only available in thc TE{(f,

Instructor Resources on Evolve.

Copyright @ 2015 by Saunders, an imprint of Elsevier Inc. All rights teserved.

C}L{PTER 1S r Er-aluation and \{anagement (E/M) Services

Emergency Department Services, Nursing Facility, Domiciliary and Home Services

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

51. A male patient presents to the emergency department with a wrist sprain sustained in a softball game when the patient slid into home, striking his hand on home plate. The patient is in apparent pain with a swollen wrist, which he is unable to flex. An expanded problem focused history and physical examination are done. Rad?ographs show a CoIIes' fracture of the distal radius. The MDM complexity was low.

CPT Code:

ICD-10-CM Codes:

(ICD-9-CM Codes:

,./SZ. 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:

ICD-10-CM Codes:

(ICD-9-CM Codes:

Odd-numbered answers are located in Appendix B, while the full answer key is only avallable ln the TEACH Instructor Resources on Evolve.

Copyright @ 2015 by Saunders, an impdnt of Elsevier Inc. A11 rights reserved.

CHAPTER 1.5 r f1-n1g31ion ard \1.:-,:. _-..:.: : l.: :=.-

53' This is a home visit on an elderly gentleman, pre'ioush'i.inrr- -,, r-- lme, who is complaining of edemaln his iowei extremirics. f ;-r. -iassociated with this. An expanded problem focused histor:,. a:; examination are performed and ro* complexity decisior, *uiJ.. _stockings are prescribed.

CPT Code:

/54. subsequent foilow-up care is provided for the B2-year-old mare nursingfacility patient with Alzheimelr's disease. The resident has respondedwell to some new medications and appears to have recovered some ofhis cognitive abilities without behavioral disturbances. The physicianperforms a problem focused history and physicar examination on hisnerrrological problem and orders the current treatments continued. TheMDM complexity is low.

CPT Code:

ICD-1O-CM Code:

(ICD-9-CM Code:

ICD-1O-CM Codes:

(ICD-9-CM Codes:

55. Subsequent follow-up care is provided for the patient who was transferred to a skilled nursing facility from an'acute care hospital afterpartial recovery from.a stroke-The pitient has deveroped periods ofextreme dizziness and mental confusion. A detailed iiterval historv isgathered, and a detailed physical examination of the

"ff".i;; b.;; "

systems is performed. Given the possibility that a new stroke could ha'eoccurred or that other neurological problems have developed, neworders are written, and the ptrysician plans to return the next day toevaluate the patient's condition again. The MDM compiexity is moderate.

CPT Code:

ICD-10-CM Codes:

(ICD-9-CM Codes:

copyright @ 2015 by Saunders, an imprint of Eisevier Inc. Alr rights reserr.ed.

_-

--.--------.-------.------.------..------.-._--)

146- the physician provides services to a resident of a rest home for,:,ulcerative sore on the heel and midfoot. Given the fact that ih.:-1r-.:r: is in reasonabry good health and is not diabetic, tne pn.:sic,";' --....his attention on the right lower extremity during the prcbl.::. - -.--._:physical examination. The physician knows the resideni ,.r;- 11_performs a brief HpI and ROS during a problem focused l_:: - - , , _,.resident thinks the sore is from new=shies, and the p.i.rl.-,-,_ ,. -,-_.

odd-numbered answers are located in Appendix B, while the full answer kev is onl\- a'ailable in the TE \f HInstructor Resources on Evolve.

r=il9[8. 15 r Srpa-,i"o ad ]arnrGffit ,E\f, Sersic.es

with that corclusion. Topical antibiotic cream is ordered, and the new shoes are sent to the cobbler to be stretched. The MDM complexity is straightforward.

CPT Code:

ICD-IO-CM Code:

flCD-g-CM Code:

57. The physician provides services to a new patient who is in a custodial care center. The patient is 43 years o1d and is paraplegic, with severe infected stasis ulcers. The physician performs a detailed history and examination and prescribes an antibiotic. The MDM was straightforward.

CPT Code:

Pyolonged Services and Preventive Medicine Services 4g. 'Mestablished patient is seen in the offlce 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:

59. A 44-year-ord asthmatic patient (new) is scheduled for a routine office visit for a complaint of severe headaches. The physician provides a comprehensive history and examination. The MDM complexity was high. Toward the end of the visit, the patient develops severe breathing complications, and the physician spends the next hour and 30 minutes administering treatment.

CPT Codes:

/ ,/OO. e 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:

Services from Throughout the E/M Section 61. A new patient is seen in the office for a variety of medical problems.

The patient has insulin-dependent diabetes mellitus with complicating eye and renal problems. She also has hypertensive heart disease with episodes of congestive heart failure. Her peripheral vascular disease has

Odd-oambered answers are located in Appendix B, whlle the full answer key ls only available in the TBACH Instrsctor Resources on Evolve.

Copyright O 2015 by Saunders, an imprint of Elsevier Inc. A11 rights reserved.

CHAPTER 15 r Evaluation and Management (T/Ml Ssrices

worsened, and she can walk only a block before she is crippled with extreme leg pain. The patient reports that a new problern has surfaced throbbing headaches with radiating neck pain. To manage and investigate the multiplicity of problems, the physician performs a comprehensive history and physical examination. A complete review of systems is performed, as is an update to her complete past, family, aad social history. The physician has to take a multitude of factors into consideration because this patient's problems are highly complex.

CPT Code: ./

1. Onew 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 acute pharyngitis and straightforward decision making was performed. Amoxicillin was prescribed.

CPT Code:

ICD-1O-CM Code:

(ICD-9-CM Code:

63. This is a 3}-year-old female patient admitted for observation after an allergic reaction to her pain medication. She is alert and oriented, but has severe pruritus and shortness of breath. A detailed history and examination is performed after she takes medication for the pruritus; the breathing improved and the patient was discharged from observation on the same day.

CPT Code:

ICD-10-CM Codes:

(ICD-9-CM Codes:

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:

ICD-1O-CM Codes:

(ICD-9-CM Codes:

Odd-numbered answers are located in Appeadlx B, while the full answer key is only aveibllc tr |lc IEA(E Instructor Resources on Evolve.

Copyright @ 2015 by Saunders, an imprint of Elsevier Inc. A11 rights reserved.

J,^

CIL{PTER. 15 r Erzluation and Management (EM) Services

65. A family practice physician who is treating a ZO-year-old man (inpatient) for bronchitis calls in a urologist to examine the patient, who has requested a circumcision. The consultant performs a problem focused history and problem focused physical examination and determines that there is no urgency for the surgical procedure. The physician's decision making is fairly straightforward, and he recommends that the patient have the procedure done as an outpatient at a later date.

, CPT Code: t-/

,/rU. O physician visits a 7S-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 ptan 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:

ICD-1O-CM Codes:

(ICD-9-CM Codes:

67. A 67-yearold female is admitted with severe exacerbation of her COPD. The patient is now in respiratory failure and CHF. The patient is intubated and unconscious; 155 minutes of critical care time was spent at bedside and coordinating care for this patient.

& cpr code(s):

@ Ico-ro-cM code(s):

1& tco-o-cM code(s):

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

CPT Code:

ICD-10-CM Code:

(ICD-9-CM Code:

S ut r to decide number of codes necessary to correctly answer the questlon. Odrllrnhmd aD,:fiit-ens are located in Appendix B, while the full answea key is only available in the TEACH hfrxtor Besoqrccs on Evolve.

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