A 45-year-old established patient with rheumatoid arthritis, hypertension, and hyperlipidemia presents for an office visit. His joint disease has been stable in the past, but in the last three weeks he has noticed increas- ing pain and has developed redness in several joints. He has had a low-grade fever for the past week. The evening before the visit, Dr J reviews the patient's recent test results for 15 minutes. At the visit, Dr J reviews the medical history form completed by the patient and vital signs obtained by the medical assistant. A history including prior response to treatment, a review of inter- val correspondence with other providers, and a relevant examination are performed. The likely progression of disease is discussed with the patient. Lab work to rule out systemic infection is ordered. A treatment plan is updated with a new medication prescription provided. The patient has considerable anxiety regarding the new medication and the potential risks, and Dr J provides additional information and counseling. Appropriate medical record documentation is made with a notation to follow up on the lab work results and to revise the treatment plan, as necessary. Dr J spends a total of 60 minutes in face-to-face and non-face-to-face activities relating to the visit. Using time as the basis for code selection, which E/M code(s) should be reported for this case study?

Phlebotomy Essentials

6th Edition

ISBN:9781451194524

Author:Ruth McCall, Cathee M. Tankersley MT(ASCP)

Publisher:Ruth McCall, Cathee M. Tankersley MT(ASCP)

Chapter1: Phlebotomy: Past And Present And The Healthcare Setting

Section: Chapter Questions

Problem 1SRQ

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A 45-year-old established patient with rheumatoid arthritis, hypertension, and hyperlipidemia presents for an office visit. His joint disease has been stable in the past, but in the last three weeks he has noticed increas- ing pain and has developed redness in several joints. He has had a low-grade fever for the past week. The evening before the visit, Dr J reviews the patient's recent test results for 15 minutes. At the visit, Dr J reviews the medical history form completed by the patient and vital signs obtained by the medical assistant. A history including prior response to treatment, a review of inter- val correspondence with other providers, and a relevant examination are performed. The likely progression of disease is discussed with the patient. Lab work to rule out systemic infection is ordered. A treatment plan is updated with a new medication prescription provided. The patient has considerable anxiety regarding the new medication and the potential risks, and Dr J provides additional information and counseling.

Appropriate medical record documentation is made with a notation to follow up on the lab work results and to revise the treatment plan, as necessary. Dr J spends a total of 60 minutes in face-to-face and non-face-to-face activities relating to the visit. Using time as the basis for code selection, which E/M code(s) should be reported for this case study?

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