INPATIENT HOSPITAL Gender: M
Age: 72 (Medicare)
Chief complaint: Presented to ED with complaints of chest pain, SOB
History: Comprehensive. Extended HPI, complete ROS, complete PFSH
Examination: Comprehensive CV exam
Medical decision making: High complexity. Patient experienced a myocardial infarction while being examined and I provided 1 hour, 20 minutes of critical care in addition to the other services provided. Patient was stabilized and subsequently admitted by me.
a. In what setting was the service provided: office or outpatient, inpatient hospital, or another setting (specify)
b. What type of service was provided: management of a health problem, preventive care, consultation only, or other?
c. Is the encounter initial or subsequent?
d. What code range is applicable for the basic service in type of encounter? What is the title of the subcategory?
e. What criteria are used to determine the basic level of service?
f. What level of history was taken by the provider?
g. What level of examination was performed?
h. What was the complexity of medical decision making?
i. How much time was spent on additional services beyond the basic evaluation and management?
j. What code range is applicable for the additional service? What is the title of the subcategory?
k. What criteria are used to determine the additional service?