Exercise 10.3

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Pima Community College *

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HIT-102

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Medicine

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Feb 20, 2024

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Exercise 10.3 – Levels of E/M Services and Medical Decision Making Instructions: Complete each of the following. 1. Which code is reported for a level 3 emergency department service? 99283 2. An 89-year-old diabetic patient presented to the hospital emergency room for level 4 evaluation and management of a very painful lower left arm. An x-ray revealed left ulnar fracture. An appropriate medical history and examination was performed, and moderate level of medical decision making was documented. During the encounter, the physician reduced the fracture and applied a short- arm cast (for which a CPT Surgery section code was reported.) a. Should an E/M code also be reported for this case? (Yes or No) Yes- the physician performed a level 4 evaluation emergency department service. b. If so, which code is reported? (Enter None if no code is reported.) 99284-57 3. A 14-year-old patient presented to the primary care provider’s office for treatment of a 3 centimeter laceration, which the physician sutured. The physician also administered a tetanus toxoid after confirming that the patient’s tetanus immunization status was not up-to-date. Codes for suture repair of the laceration and administration of the tetanus toxoid were assigned from the CPT Surgery and Medicine sections, respectively. a. Should an E/M code also be reported for this case? (Yes or No) – No b. If so, which code is reported? (Enter None if no code is reported.)- None 4. Dr. Martinez performed a level 3 E/M service to treat an 18-year-old patient in the office for a urinary tract infection. The last time the patient was seen by Dr. Martinez was three months ago during a preventive medicine encounter. Urine culture revealed Escherichia coli bacteria. The patient was prescribed antibiotics and instructed to return for recheck in 10 days. a. The CPT E/M category is Office or Other Outpatient Services, and the subcategory is _________ Patient. Established b. The appropriate CPT code is _________. 99213 5. Use the case below to assign the E/M consultation code, which requires you to identify the level of medical decision making. SUBJECTIVE: A 54-year-old patient is seen in the office by an endocrine specialist for evaluation and management of type 1 diabetes mellitus; the patient also has hypertension. The patient was referred by the primary care provider (PCP) for an opinion about treatment. The patient has no new complaints today and denies chest pain, headache, numbness of the extremities, shortness of breath, or visual changes. The patient has remained on the diet recommended during the last E/M visit with the PCP and regular exercise is part of the daily routine. Home monitoring of blood pressure and glucose levels are within normal limits.

OBJECTIVE: Blood pressure 130/78. Weight 145. Pulse 78, regular. HEAD, EYES, EARS, NOSE, THROAT: Pupils equal, round, and reactive to light and accommodation. External auditory canals and tympanic membranes negative. Oropharynx benign. NECK: Supple. No bruits, jugular venous distention, or thyromegaly. CHEST: Breath sounds clear to auscultation and percussion. No rubs, rales, rhonchi, or wheezing. HEART: No click, gallop, irregularity, murmur, or rub. EXTREMITIES: Distal pulses intact. No cyanosis, clubbing, or edema. NEUROLOGICAL: Deep tendon reflexes within normal limits and symmetrical. No decreased lower extremity sensation noted. LAB RESULTS: Fasting blood sugar 132. Urinalysis within normal limits. ASSESSMENT: Type 1 diabetes mellitus, controlled. Hypertension. PLAN: Glucotrol 5 milligrams daily, every morning. Procardia XL 30 milligrams daily. Relafen 1,000 milligrams daily. Continue home glucose monitoring. SMA-7 and glycosylated hemoglobin today. Return for routine follow-up in three months. a. What is the level of medical decision making? Moderate b. Which E/M code is assigned? 99242

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Exercise 10.3

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