1. A 23-month-old infant with a heart condition presented to the ED. The physician examined the infant and , after reviewing the patient’s history of a heart condition, ordered a transport to a specialty cardiac hospital. This specialty hospital is 150 miles away from the current hospital. The physician accompanies the patient in the ambulance to monitor blood pressure and pulse oximetry and to review portable ECG tracings. It takes 1 hour and 44 minutes to transport the patient to the cardiac hospital
2. An 56-year-old established patient presents to her doctor’s office with chest pain and shortness of breath. The doctor orders an ambulance to take the patient to the ED to be checked out. From the ED the patient is admitted for some tests to determine what the problems are. The history and exam performed were comprehensive and the MDM 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 decision 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 ED physician on duty. The physician obtains an extended HPI, an extended ROS, and a pertinent PFSH. 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 MDM 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 of a neonate? 28 days or younger.
10. These elements would be part of the ____ history: employment, education, use of drugs a- Social
11. A full-term baby girl was born at a local community hospital on 07/08, at which time the infant’s APGAR 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 with the same specialty in the same group practice within the past _______ years.
14. A 13-year-old new patient presents for a well-check examination. The patient does not report any medical complaints
15. According to E/M guidelines, a(n) ____ exam encompasses a complete single-specialty exam or a complete multisystem exam Comprehensive
16. The request for advice or opinion from one physician to another physician is this type of service Consultation
17. Dr. 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 MDM was straightforward 99202
18. An out-of-town patient presents to a walk-in clinic to have a prescription refilled for a nonsteroidal 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 focused interval history, an expanded problem focused examination, and MDM 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 MDM is of moderate complexity.
21. Dr. 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 MDM 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 MDM.
23. A neonate is admitted to neonatal intensive care in critical condition and requires respiratory support, which includes ventilation. The physician directs the health care team in an attempt to stabilize the infant
24. A 75-year-old patient was just diagnosed with type 1 diabetes. This means that the patient will have to give himself insulin shots. The physician supervised the coordination of home health care, which required 30 minutes of his time
25. With two-way communication, the physician directs the EMTs in an ambulance en route to the ED with a patient in apparent cardiac arrest A: 99288
26. The request for advice or opinion from one physician to another physician is this type of service: Selected Answer: consultation
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