CCEP Lesson 9 Module 2.a Homework – Hospital Inpatient & Observation Care 99211-99239

Physician admits a patient to observation at 7:00 AM on February 3rd. They document medical decision making of moderate complexity. The patient’s condition improves throughout the day and the physician elects to discharge the patient at 9:30 PM on February 3rd. The clinician spends 47 minutes discharging the patient, explaining the patients course of care presentation and plan for further follow up. Code this encounter.

A patient presents to the emergency department for evaluation of chest pain. After discussion with the ED physician, Dr. Jones admits the patient to the hospital as an inpatient with moderate complexity MDM. Code Dr. Jones’ service:

A patient admitted to the hospital for observation, immediately following an outpatient visit at the physician’s office for acute abdominal pain. Evaluation shows relevant history/exam, with medical decision making of low complexity. Later that same day, the same physician discharged the patient. Code the hospital service.

A physician returns to evaluate a patient on day 2 of a hospital admission for significant GI pain. Multiple studies had been previously ordered with results that are now ready for review. The physician spends a significant amount of time reviewing the patients chart including: results of imaging and other studies, evaluating the patients’ presentation and personally speaking to the patient and family members twice during the day. The physician documents a total time spent on patient care for the day of 73 minutes for this high complexity medical decision making presentation. Code the physicians services for this day.

A physician returns to evaluate a patient on day 3 of a hospital inpatient admission for significant and abnormal chest pain. Multiple studies had been previously ordered. The physician spends a significant amount of time reviewing the patients’ chart and personally speaking to the patient and family members both, in the morning and again that night, about the plan for treatment. Then discharging the patient that night (day 3). The physician documents 53 minutes spent on observing the patient, reviewing studies and developing the discharge plan. Code the physicians services for this day.