A 3-year-old established patient is seen in the physician's
office for crying and pulling on his left ear. The patient's
mother states he has been crying for hours and that she has
not taken his temperature, but he feels warm. A medically
appropriate history and physical examination is performed,
which reveals otitis media with otorrhea. The physician
prescribes 250 mg of Ceftin twice a day for 10 days and four
Ciprodex drops in the ear twice a day. The patient's mother is
instructed on the appropriate use of the medication and
potential side effects. The patient is to return to the office in
two weeks for follow-up.
The documentation supports the following:
• Complexity of problem (acute, uncomplicated illness or
injury)
• Amount and complexity of data (independent historian
[mother])
• Risk (prescription drug management)
What E/M code needs to be asssigned?
Question 1 options:
99212
99205
99213
99215
The primary care physician orders a CT of the thorax (CPT
code 71250) along with an x-ray of the thoracic spine (CPT
code 72070) to be performed at the local hospital. The results
will be called into the office. According to the Amount and
Complexity of Data category, this would count as:
Question 2 options:
Discussion of management or test interpretation
Independent interpretation of test
Two unique tests
One unique test
