Rationale: For an emergency visit, all three key components must be met: History—HPI (Brief), ROS (Extended), PFSH (none) = Expanded Problem Focused Exam—Detailed (extended exam of constitutional, skin, neck, neurologic) MDM—Moderate for (new problem to examiner with additional work-up [additional tests were ordered to rule out meningitis]; order of radiology test (1 point); level of risk moderate [lumbar puncture] The documentation supports 99283.
Answer: C. 99223
Rationale: Initial hospital care codes require all three key components be met to determine a level of visit. In this case, the comprehensive history and exam, and the high level of medical decision making support a 99223.
Answer: B. 99283
Rationale: For an emergency visit, all three key components must be met: History—HPI (Extended), ROS (Extended), PFSH (none) = EPF Exam—Expanded problem focused (limited exam of ears, nose, throat, and neck) MDM—Moderate for the prescription drug management The documentation supports 99283.
Answer: C. 99309 Rationale: For subsequent nursing facility care codes, two of three key components must be met. History—(Extended), ROS (Extended), PFSH (1-Pertinent) = Detailed Exam—Detailed exam of eyes, ENT, Neuro MDM—New problem with additional workup, lab ordered, moderate risk (undiagnosed new problem with uncertain prognosis) = moderate medical decision making The documentation supports 99309.
Answer: B. 99243
Rationale: A consultation requires all three key components be met to support the level of visit. History—HPI (extended), ROS (Extended), PFSH (complete) = Detailed Exam—Detailed MDM—New problems no additional work-up, one data point given (review/order of test in medicine section) for the EMG or Nerve conduction study. The level of risk is moderate (elective major surgery). The documentation supports a 99243.
