1. A physician is called to the intensive care unit to provide care for a patient who received second- and third-degree burns over 50 percent of his body due to a chemical fire. The patient is in respiratory distress and is suffering from severe dehydration. The physician provides support for two hours. Later that day the physician returns and provides an additional hour of critical care support to the patient.
2. A 23-month-old infant with a heart condition presented to the ED. The physician examined the infant and , after reviewing the patient’s history of a heart condition, ordered a transport to a specialty cardiac hospital. This specialty hospital is 150 miles away from the current hospital. The physician accompanies the patient in the ambulance to monitor blood pressure and pulse oximetry and to review portable ECG tracings. It takes 1 hour and 44 minutes to transport the patient to the cardiac hospital.
3. A full-term male born with birth weight of 1400 grams is being monitored in PICU for respiratory and cardiac problems. This is the second day of his stay in PICU, and the infant is doing well on oxygen therapy. Code this second day.
4. 75-year-old man with a medical history that includes BPH, HTN, and NIDDM presents to his primary care physician for his six-month check-up. The patient is taking all prescribed medications and needs a refill of his hypertensive medication. The physician counsels the patient at this session on ways to reduce his prostatic hypertrophy that include laser surgery and microwave therapy.
5. A 16-year-old outpatient who is a new patient to the office complains of severe facial acne. The history and physical examination are expanded problem focused. The physician must consider related organ systems in addition to the integumentary system in order to treat the condition. With minimal number of diagnoses to consider and the minimal amount of data to review, the physician’s decision making is straightforward with regard to the treatment of this patient.
6. Dr. O’Donnel treated a 42-year-old male in the hospital emergency department. The patient complained of right lower quadrant pain and of feeling faint. Dr. O’Donnel documented a chief complaint, a brief history of present illness, and a systemic review of the gastrointestinal system and respiratory system. Dr. O’Donnel also documented a complete examination of all body systems, which included all required elements. Medical decision making was of moderate complexity.
7. A full-term baby girl was born at a local community hospital on 07/08, at which time the infant’s APGAR scores were 9 and 10 and the normal infant was examined prior to her admission to the nursery. On the second day of admission (07/09), the normal newborn was discharged home with her mother. Code the discharge.
8. Dr. Williams treated a 9-month-old new female patient in the office for diaper rash. An expanded problem focused history and exam were performed, and MDM was straightforward.
9. A 72-year-old patient with a history of breast cancer has a suspicious mass in her uterus. A biopsy was done. The determination was that the patient had a carcinoma in situ of the uterus. The physician who conducted the surgery called a face-to-face meeting with his fellow surgeons, the patient and the patient’s family and discussed the case and the patient’s outcome for 30 minutes.
10. Dr. Martin provided 1 hour and 20 minutes of critical care services to Jack Smithton, age 64, who is in the Intensive Care Unit with acute respiratory distress syndrome 11.