Dr Smith went to see his patient, an 87-year-old male, for his monthly visit to the nursing home. She documented a problem-focused interval history and the medical decision-making was straightforward. Dr Smith did not examine the patient because he was too agitated. The correct E/M code to report for Dr Smith is:

At the patient’s request, Dr Smith spent 15 minutes on the telephone speaking with Roger about an electronic report that Dr Smith received from Roger’s insulin pump. Roger had complaints of fatigue and difficulty sleeping. Dr Smith reiterated his advice from his appointment eight days prior that Roger must monitor his blood sugar and not let the pump’s volume get too low. No appointments were made; however, Dr Smith advised Roger to inform him if his complaints persisted. The correct E/M code to report for Dr Smith is:

Name the three key components in selecting a level of E/M service.

History, examination, medical decision making [BLANK-1]

Coding requires good documentation, ongoing education, and experienced staff?

A patient is referred by his physician to see an orthopedic surgeon for a consultative service. During the first visit with the orthopedic surgeon, he or she initiates diagnostic or therapeutic service. After the visit is completed, opinion or advice is rendered back. Would this encounter be considered a consultation?

A 61-year-old male patient was brought into the emergency department (ED) after having lost consciousness in a grocery store. The ED physician took an expanded problem focused history and performed a detailed exam. The medical decision-making was of moderate complexity. The correct evaluation and management (E/M) code to report for the ED physician is 

A person who has received professional services from the physician or QHP or another physician or QHP of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.

Counseling, as it relates to the E/M components, is partially defined as a discussion with the patient and/or the patient’s family member(s) or other caregiver(s) concerning diagnostic results, impressions, and/or recommended diagnostic studies.

When did the development and use of Level II of the HCPCS begin?