Level/Complexity of MDM

Instructions: Select the most correct response.

Question

1) A patient presents to the emergency department after having twisted his ankle while playing football with a group of friends. The patient complains of pain in his left ankle. The physician examines the patient’s ankle, notes swelling and tenderness, and obtains an X-ray to rule out any fracture. The nursing staff places the patient’s ankle in a soft cast before the patient leaves. This level/complexity of MDM was

Responses

• Low

• moderate

• high

• straightforward

2) What is the correct code range for the subcategory of inpatient Critical Care Services for a pediatric patient?

Responses

• 99466–99467

• 99471–99476

• 99468–99469

• 99281–99288

3) The physician treated a new patient in the office and the following was documented: This 35-year-old single female has just recently moved to area. S: Patient needs refill on medication for hypertension. Patient also complains of “soreness” of her right elbow. No recent physical trauma. O: Limited range of motion, right elbow. Tenderness upon palpation. BP 140/80. A: Possible tennis elbow. Send for radiographs of elbow this week. Scripts given for atenolol for BP. P: Schedule appointment in one week to review X-ray results and check BP.

Which part of this note is used to determine medical decision making?

Responses

• Schedule appointment in one week to review X-ray results and check BP.

• Limited range of motion, right elbow

L

• Possible tennis elbow. Send for radiographs of elbow this week.

• Patient complains of “soreness” of her right elbow.

4)Which category/subcategory of evaluation and management would be reviewed to select an appropriate code documented as follows: This 35-year-old single female has just recently moved to area. S: Patient needs refill on medication for hypertension. Patient also complains of “soreness” of her right elbow. No recent physical trauma. O: Limited range of motion, right elbow. Tenderness upon palpation. BP 140/80. A: Possible tennis elbow. Send for radiographs of elbow this week. Scripts given for atenolol for BP. P: Schedule appointment in one week to review x-ray results and check BP.

Responses

• Preventive Medicine Service, New Patient

• Office or Other Outpatient Services, Established Patient

• Office or Other Outpatient Services, New Patient

• Office Consultations

5) What are the key components of an E/M service for Emergency Department Services?

Responses

• Time

• Medical decision-making, examination, and time

• History, examination, and medical decision-making

• Medical decision-making only

6) The provider saw a patient for a subsequent hospital visit. The patient is post-tonsillectomy XH 2 days. Patient is still unable to speak in a clear voice. Bleeding has increased in the surgical area. Patient will have to be taken back to the operating room for hemorrhage control. Which level of MDM is documented?

Responses

• Straightforward

• High

• Moderate

• Low

7) The patient presents to the emergency department with the chief complaint of difficulty swallowing. All types of food are a problem. Liquids are not. The patient does not report any chest pain or pain when lying down. The patient has pain only when swallowing; the pain is a severe burning-type pain. He has been eating soft foods and soups for the past two weeks. This problem started two weeks ago and slowly has gotten worse over time. The patient is on no medications. The patient has a family history of breast and colon cancer. The patient is a former one-pack-per-week smoker. He quit smoking 10 years ago. The ROS is positive for joint pain in the right knee on and off. No medication or treatment for this. The patient did injure his knee as a child in a skiing accident, but that was 30 years ago. Remainder of ROS is negative. Which level of medical decision-making is documented?

Responses

• Low

• Straightforward

• High

• Moderate

8) The following was documented on the initial visit note for a new patient at a skilled nursing facility (SNF). The patient is a 55-year-old female who suffered a stroke on December 14. The patient’s daughter found her on that date, unconscious on the kitchen floor. It was not known how long the patient was there. The patient was taken to Valley Road Hospital and was admitted for treatment. Severe left-sided hemiplegia and dysphasia were present at admission to hospital. The patient also has a history of type 2 diabetes mellitus and GERD. Current orders from hospital attending are for sliding scale of insulin injections. The patient also has a feeding tube present. The left-sided hemiplegia is still present and is of a moderate nature, and the patient will require physical and speech therapy. The patient is admitted for physical and speech therapy. Her blood sugars will be closely monitored, and her tube feedings will continue. Which level of medical decision-making is documented?

Responses

• Moderate

• Straightforward

• High

• Low

9) The following is documented on the observation note of a patient: The patient was admitted yesterday to the observation unit with the r/o diagnosis of severe back pain. The patient was in an automobile accident prior to admission to the unit. Physical exam at the time was negative for any fractures. Radiology reports were also negative for any fractures. However, due to the patient’s severe discomfort, he was admitted for observation. Examination on day 2 in the unit shows a 45-year-old man in moderate distress despite prescription analgesics. MS: Pain over the lower lumbar region, ROM is limited especially on the left side. No visible swelling but tenderness on palpation. Muscle strength and tone normal on right. Decreased on left. Gait abnormal with leaning at midsection. Plan: Reexamine radiograph reports and films. Possible MRI of lumbar spine to rule out herniation of disc. Which level of medical decision-making is documented?

Responses

• Low

• High

• Moderate

• Straightforward

10) The following information was documented on a patient seen in the physician’s office. Review of lab tests and uroflowmetry suggests benign prostatic hypertrophy. The patient’s urine flow was 8 mm. PSA test was slightly elevated. Repeated PSA today. TURP was discussed with patient. Risks and benefits of procedure discussed in detail. Patient has agreed to surgery. Surgery will be scheduled for next week. Which level of medical decision-making is documented?

Responses

• Low

• Straightforward

• Moderate

• High

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