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Problem-Focused History and Physical Examination

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    The doctor orders an ambulance to take the patient to the DEED to be checked out. From the DEED the patient is admitted for some tests to determine what the problems are. The history and exam performed were comprehensive and the MD was of moderate complexity 3. An established patient was seen in her primary physician’s office. The patient fell at home and came to the physician’s office for examination. Due to a possible concussion, the patient was sent to the hospital to be admitted as an observation patient.

    A detailed history and examination were performed, and the medical session was of low complexity. The patient stayed overnight and was discharged the next afternoon. Report code(s) 4. Critical care codes are reported based on: 5. Mr.. Smith presents to the Emergency Department at the local hospital for chest pain and is seen by the DEED physician on duty. The physician obtains an extended HIP, an extended ROSS, and a pertinent PUSH. What is the level of history 6. A new patient with a history of mental retardation and self-abuse is sent to a custodial care facility for admission.

    The patient’s family is no longer able to care for the patient at home. The care facility physician documents a problem focused history and exam. The MD was straightforward 7. Only one consultation should be reported by a consultant per admission. What range of codes should be used for any subsequent inpatient services provided by the consultant? 8. A 50-year-old female has brain cancer, and the physician supervised the coordination of hospice services, which required 45 minutes of his time. 9. According to information in 99468, what is the age off neonate? 28 days or younger. 0. These elements would be part of the use of drugs a- Social story: employment, education, 11. A full-term baby girl was born at a local community hospital on 07/08, at which time the infant’s PAGER scores were 9 and 10 and the normal infant was examined prior to her admission to the nursery. On the second day of admission (07/09), the normal newborn was discharged home with her mother. Code the discharge 12. Which of the following codes is reported when a physician, at the request of the attending physician, is standing by in case his or her services are needed 13.

    A new patient is “One who has not seen the physician or another physician tit the same specialty in the same group practice within the past years. 14. A 1 3-year-old new patient presents for a well-check examination. The patient does not report any medical complaints 15. According to MIM guidelines, a(n) exam encompasses a complete single- specialty exam or a complete multistage exam Comprehensive 16. The request for advice or opinion from one physician to another physician is this type of service Consultation 17. Dry. Williams treated a 9-month-old new female patient in the office for diaper rash.

    An expanded problem focused history and exam were performed, and MD was straightforward 99202 18. An out-of-town patient presents to a walk-in clinic to have a prescription refilled for a nonessential anti-inflammatory drug. The physician performs a problem focused history and physical examination with straightforward decision making 99201 19. A 21 -year-old patient with a recent history of drug abuse is admitted to a rehab center for treatment. In the patient’s second week of treatment, she complains of low back pain and is seen by the same physician who evaluated her medically upon admission.

    At this time, the physician documents a problem soused interval history, an expanded problem focused examination, and MD of low complexity 20. A patient was in an automobile accident and is complaining of a minor headache and no other apparent injuries. History gathered from bystanders states that the patient was not wearing a seat belt and hit his head on the windshield. A 15-minute loss of consciousness was noted. The patient was then admitted for 24-hour observation to rule out head injury. A comprehensive history and exam are performed by the physician. The MD is of moderate complexity. 1. Dry. Lewis treated an established patient in the office who complained of a 3- month history of fatigue and weight loss. An detailed history was performed, exam was detailed and MD was high. What code would be used? 22. An office consultation is performed for a postmenopausal woman who is complaining of spotting in the past 6 months with right lower quadrant tenderness. A comprehensive history and physical are performed with a low complexity MD. 23. A neonate is admitted to neonatal intensive care in critical condition and requires respiratory support, which includes ventilation.

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