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A 21-year-old patient with a recent history of drug abuse is admitted to a rehab center for treatment. In the patient’s second week of treatment, she complains of back pain and is seen by the same physician who evaluated her medically upon admission. At this time, the physician documents an interval history and examination and MDM of moderate complexity.
A new patient diagnosed with mild intellectual disabilities and self-abuse is sent to custodial care for admission. The patient’s family is no longer able to care for the patient at home. The care facility physician documents an appropriate history and exam. The medical decision making documented was straightforward. Assign the CPT code(s).
A 64-year-old patient has diabetes and has been having problems adjusting her insulin doses. She has had an onset of dizziness and sensitivity to light. Her primary care physician, who has treated her for this condition for the past 4 years, made a home visit today. At this visit, the physician performed an extensive history and exam. The patient’s condition is moderately severe, and the MDM is of a moderate level. Time spent on this patient’s care is as follows: Travel time was 23 minutes, history/exam was 25 minutes, discussion of treatment plan was 35 minutes. Assign the CPT code(s).
A 15-year-old new patient has cystic fibrosis and is having problems with her Pulmozyme dosage. The patient has moderate throat pain and slight tightness in her chest. The physician makes a home visit and performs extensive history and exam. The MDM complexity is of a moderate level. Assign the CPT code(s).
A 32-year-old new patient is seen at Hotel Casa Bonita. She is complaining that she is nauseous and has sensitivity to light and sounds at least once every couple weeks. The physician completes the history and examination. It is determined that she has migraines. Rx is given to try for the next month. The MDM is low. Assign the CPT code(s).