Question

I & II

Delia presented to her current primary doctor complaining of a sore right knee due to falling down her stairs at home. During the examination the provider noted a bruised swollen toe that appeared broken. The provider ordered x-rays for the knee and toe. Results indicated no breaks. The provider documented an expanded problem focused history and examination and straightforward medical decision making. The provider listed Delia's diagnoses as follows: 1. Sprained right knee medial collateral ligament. 2. bruised left fifth digit toe. The doctor prescribed the following plan of treatment. Provide brace on knee for three weeks. Ice and elevate both knee and toe three times a day for three weeks. Return if pain persists or swelling worsens. Below are descriptions of three EM Codes. and explain your answer Decide which one you would assign and explain why. Identify code here 1. Established Outpatient: CPT Code 99212 E/M Problem Focused History E/M Problem Focused Exam E/M Straightforward Medical Decision 2. Established Outpatient: CPT Code 99213 EM Expanded Problem Focused History EM Expanded Problem Focused Exam E/M Low Complexity Medical Decision 3. New Outpatient: CPT Code 99202 E/M Expanded Problem Focused History - EIM Expanded Problem Focused Exam EMt Straigndorwand Medical Decision l From the case from question 36, what would be the first listed condition and what code would you assign for this condition? Identify code here

Answer 1

3. New outpatient is the answer as Delia is the out patient department patient who came with the complaints of fall and with minor injuries were by the related problem focused history was collected and analysed, the examination was done on the areas were problem arises and the medical decision was taken up.