Hcr Axia College

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Date Submitted: 09/12/2010 07:53 PM

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o Initial consultation for a 78-year-old woman with unexplained weight loss, abdominal pain, and rectal bleeding. Comprehensive history and examination performed.

The patient seems to be a new patient. There was a comprehensive history performed. The examination was also a comprehensive examination. Code range: 99204-99205

 o 30-year-old patient presents complaining of flu-like symptoms characterized by unremitting cough, sinus pain, and thick nasal discharge. Examination reveals bronchitis and sinus infection. Patient is prescribed a five-day course of Zithromax.

The patient could be an established patient. Both history and examination seem expanded problem focused. The medical decision making could be low complexity.

Code: 99213

o Established patient on Lithium presents for routine blood work to monitor therapeutic levels and kidney function. Nurse reviews the results and advises the patient that tests are normal and no change in dosage is indicated.

The patient is an established patient. The history and examination is detailed. The medical decision making is moderate complexity.

Code: 99214

 o 62-year-old diabetic female presents for check-up and dressing change of wound on left foot. Examination reveals that the wound is healing. Nurse applied new dressing and patient will return for check-up in one week.

The patient seems to be an established patient. The history and examination are both minimal. The medical decision making is straightforward.

Code range: 99211-99212

 o A mother brings in her six-month-old male child for routine wellness check. Examination reveals the child to be in good health and making adequate progress.

The patient is established and the history is minimal. The examination is expanded problem focused because all areas of the child’s health are checked out. The medical decision making is straightforward.

Code: 99212