questions about beginning to take an antioxidant since she has a family history
ID: 84667 • Letter: Q
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questions about beginning to take an antioxidant since she has a family history of ovarian cancer Carrie is seen by Dr Lennox. The physician documents a detailed history, a comprehensive examination, and medical decision making of moderate complexity. Is the patient new or established? identity the CPT category and subcategory. 3. A patient was treated in the emergency department (ED) following a fall from a ladder The patient was ly 40 feet. He presents to the hospital ED cleaning the gutters on his home when he fel with complaints of right leg and ankle pain. The patient also has multiple contusions, abrasions, and of his trunk, legs, and forearms. He is sent to xray to rale out fractures of his leg and ankle. The ED physician documents a detailed examination, medical decision making of moderate complexity. and a detailed history Is the patient new or established? identify the CPT category and subcategory. 4. Millie Lawton is a 5year-old female seen for her annual physical. She has been seeing the same physician for this physical for the past five years. Millie has a history of hypertension, currently controlled by diet and exercise, and osteoarthritis, for which she takes Advil. She has been compliant with her diet and exercise program, and she has no new medical complaints, Routine blood work was ordered, and she was instructed to call for an appointment if she has any problems or questions. The physician will call her to report the blood work results Is the patient new or established? identify the CPT category and subcategory. 5. Seventy five-year-old Milton Gray was admitted to the Alzheimer Unit at the Shady Hills Nursing Facility. The facility's medical director examined Mr. Gray upon his admission to the facility and documented detailed examination and medical decision making of moderate complexity. Mr Gray was unable to provide a history: therefore, the medical director, Dr. Perez, used medical records from Mr. Grays private physician and spoke with the patient's wife and son. He ed that the patient was previously diagnosed with type 2 diabetes melitus, hyperlipidemia, and gout. Dr. record and his conversation with the family in the patients record (detailed history) Is this an initial on subsequent visit? Identify the CPT category and subcategory. 6. The following history information was documented in the office record of Ms. Sally Wells. Use the E/M CodeBuilder (Appendix ll of your textbook) to determine the level of history performed. Patient complains of blurring vision, eye redne and tearing. This HISTORY the past three weeks. The patient's boyfriend has been happening on and off for gave her a kitten for a birthday present. The kitten sleeps vith the patient er eye drops and cool in her bed. The patient haa tried over-the-count The patient has no history of The patient is on no nedications compresses problems or allergies to The patient reports no skin problems or respiratory problems in the past. Normal childhood diseaaes including chickenpox and measles. The patient does have a fanily history of allergies and asthma. The patient doen not smoke or take any recreational drug Level of history periormed 7. The following examination findings were documented on a patient seen in Dr. Blake's office. Use the E/M Code Builder (Appendix ll of your textbook) to determine the level of examination performed. Appears in good health, no complaints General: lities seen soft and nontender Regular rate and rhythm Heart No abnormalities Respiratory Genitalia Deferred cument Procedural Terminology c 2009 American Medical Assecatan ALL RIGHTS RESERVEDExplanation / Answer
3. The patient is new as he has not been seeing the same doctor The patient and is evident from the patient presenting his past history. This is category II of CPT, with Diagnostic/screening processes or results as subcategory.
4. The patient is established with the doctor and it is CPT category I with evaluation and management as subcategory.
5. The patient is new . With category II CPT with Therapeutic, preventive or other interventions as subcategory.
6.
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