Question

1. Established patient office visit with a comprehensive history, comprehensive examination, and high-complexity medical decision making, resulting in a decision for major surgery the next day. CPT Code(s)

                                                                                                               

2. A 45-year-old male presents to the ER, where an open fracture of the left radius is diagnosed. Patient is admitted and ER physician requests surgery consult. Surgeon performs comprehensive history, comprehensive examination, and medical decision making of high complexity. Surgery is scheduled for the next day. (Code for the surgeon only). CPT Code(s)

                                                                                                               

3. A new patient was seen in the physician’s office for abdominal pain. The physician performs a detailed history and comprehensive examination. Medical decision making is of moderate complexity. CPT Code(s)

                                                                                                               

4. A patient with rectal bleeding was seen in the office of a gastroenterologist. The patient’s primary care physician requested that the gastroenterologist provide advice about this case. The specialist conducted a comprehensive history and exam, and medical decision making was high. The consultant documented his findings and communicated them via written report to the primary care physician. CPT Code(s)

                                                                                                               

5. An established patient is seen for his monthly B12 injection. The nurse performs the service under the physician’s supervision. CPT Code(s)

                                                                                                               

6. A new patient is seen in the physician’s office for a cough, sore throat, and fever. The physician performs a problem-focused history and exam, and medical decision making was straightforward. CPT Code(s)

                                                                                                               

7. Set-up and patient education regarding the use of equipment for remote monitoring of blood pressure, pulse oximetry, and respiratory flow rate. CPT Code(s)

                                                                                                               

8. Established patient office visit for evaluation of a hard lump on his shoulder, status post appendectomy 10 days ago. Problem-focused history, problem-focused examination, straightforward medical decision making. CPT Code(s)

                                                                                                               

9. Emergency department visit for a painful sunburn with blister formation on the back. Problem-focused history, problem-focused examination, straightforward medical decision making. CPT Code(s)

                                                                                                               

10. Referred to office by PCP for consult for avascular necrosis of the left humeral head due to trauma. Detailed history, detailed examination, and medical decision making of low complexity. CPT Code(s)

                                                                                                                

11. Office visit for 18-year-old new male patient with cystic acne of the face unresponsive to over-the-counter medications. Expanded problem-focused history, expanded problem-focused examination, straightforward medical decision making. CPT Code(s)

                                                                                                                

12. Initial hospital visit for one-day-old with cyanosis, respiratory distress, and tachypnea. CPT Code(s)

                                                                                                                

13. Established patient admitted for outpatient observation following medication reaction with nausea and vomiting and dizziness. Comprehensive history, comprehensive examination, moderate-complexity medical decision making. CPT Code(s)

                                                                                                                

14. First office visit of 20-year-old female for annual Pap test and discussion of contraception options. CPT Code(s)

                                                                                                                

15. Required new patient office visit for worker’s compensation evaluation of acute four-extremity weakness and shortness of breath one week after exposure to toxic chemicals. Comprehensive history, comprehensive examination, medical decision making of high complexity. CPT Code(s)

                                                                                                                

16. Established patient seen at 6:30 p.m. by nurse after regular office hours requesting a return-to-work certificate for resolving contact dermatitis. CPT Code(s)

                                                                                                                

17. Initial care management for psychiatric collaborative care for a patient with bipolar I disorder, requiring a behavioral health assessment, establishment of a care plan, and brief interventions, 100 minutes during the month. CPT Code(s)

                                                                                                                

18. Emergency department visit for a 24-year-old who fell off a trail bike and sustained a head injury with loss of consciousness for approximately 5 minutes. Detailed history, detailed examination, medical decision making of moderate complexity. CPT Code(s)

                                                                                                                

19. First office visit for removal of mole. Patient also asks physician to evaluate ingrown toenail. Expanded problem-focused history, expanded problem-focused examination, straightforward medical decision making. CPT Code(s)

                                                                                                                

20. First hour of critical care for a patient with acute respiratory failure from acute exacerbation of chronic obstructive emphysema. CPT Code(s)

                                                                                                                

21. Subsequent hospital visit for maintenance of analgesia using an IV Dilaudid infusion. Expanded problem-focused history, problem-focused examination, straightforward medical decision making. CPT Code(s)

                                                                                                                

22. Consultation by ophthalmologist requested at a psychiatric residential treatment center for possible purulent bacterial conjunctivitis. Problem-focused history, problem-focused examination, straightforward medical decision making. CPT Code(s)

                                                                                                                

23. Office visit for an established patient with a history of bipolar disorder and migraine headaches complaining of auditory hallucinations. Comprehensive history, comprehensive examination, medical decision making of moderate complexity. CPT Code(s)

                                                                                                                

24. Established patient seen by his personal nephrologist, who was called to the emergency department at midnight because patient presented with new-onset peripheral edema and increased blood pressure three months post kidney transplant. Detailed history, comprehensive examination, medical decision making of high complexity. CPT Code(s)

                                                                                                                

25. Critical care services in the emergency department for a patient in respiratory failure and with congestive heart failure. Ventilator management is initiated. Physician spends 1 hour 50 minutes providing critical care for this patient. CPT Code(s)