New Patient versus Established Patient Activity Instructions:

New Patient versus Established Patient Activity Instructions: Consider the following two case scenarios and ask the students to determine whether the patient is new or established. Case #1 Office visit (1/11/20) Dr. Smith: The patient was last seen by this primary care physician (Dr. Smith) on 12/22/18 for strep throat. The patient is now seen for dermatitis of unknown origin. Dr. Smith elects to refer this patient to a dermatologist (Dr. Jones) in his group practice. For the visit on 1/11/20, would this be new or established for Dr. Smith? Case #2 Office visit (1/12/20) Dr. Jones: Patient was treated for dermatitis. For this visit, would it be classified as new or established? Which of the following E/M services rely on documentation of a new patient versus an established patient? Office visits Initial hospital care Emergency department visit Prolonged services The patient was seen by a primary care specialist in the Community Partnership for persistent cough and watery eyes. Five months later, the patient saw an allergist in the same Community Partnership office. The allergist would identify this patient as: The physician documented the appropriate elements to report complex chronic care management services (99487-99489). If the total duration of the encounter was 1 hour and 45 minutes, the CPT code assignment would be: A new patient was seen in the physician’s office for a rash across the lower back. The physician performed a medically appropriate history and examination, assessment and plan that includes a prescription. The time is documented as 35 minutes. What is the appropriate E/M service code? The physician documented an initial observation care visit with a detailed history and a comprehensive examination with moderate medical decision-making. What is the appropriate E/M service code? For the subsequent hospital care E/M service, the physician documented an expanded focused-interval history and examination with low-complexity medical decision-making. What is the appropriate E/M service code? Which of the following services require using the patient’s age as a criterion for selection of E/M service? Advanced Care Planning Home Services Initial Nursing Facility Care Preventive Medicine Services The physician visits a 59-year-old patient in a group home for a chief complaint for insomnia. Documentation for this new patient includes detailed history and comprehensive examination with medical decision making of moderate complexity. Skilled Nursing Home Visit Date of service: 1/9/20 Date of last treatment: 12/22/19 The physician visited an elderly patient in the skilled care facility. The physician performed a detailed interval history, comprehensive examination, and medical decision making was of moderate complexity. In addition, the physician reviewed the medical record and recent lab results. What is the correct E/M code for this service? 10. Office Visit Date of service: 1/3/20 Date of last treatment: 2/12/18 The patient was seen for a cough and sore throat. The physician performed a medically appropriate history and physician and established an impression and plan. The physician documents a 15-minute visit. What is the correct E/M code for this service? An established patient with hypertension visits a physician’s office for a blood pressure check. The nurse performed the serviced under the physician’s supervision. A new patient with rectal bleeding was seen in the office of a gastroenterologist. The patient’s primary care physician request that the gastroenterologist provide advice about this case. The specialist conducted a comprehensive history and examination, and medical decision-making was of high complexity. The consultant documented his findings and communicated them via written report to the PCP. A new patient was seen in the physician’s office for abdominal pain. The physician documents the total time as 50 minutes. Dr. Ramirez provided critical care services in the ED for a patient in respiratory failure and with congestive heart failure. Ventilator management was initiated. Dr. Ramirez spend 1 hour and 50 minutes providing critical care for this patient. The patient is seen by his PCP for an annual physical. Dr. Gerald provided preventative medicine services to an established 45-year-old patient who was in good health and had no complaints. Dr. Gerald obtained a comprehensive history, performed a comprehensive examination, and counseled the patient on proper diet and exercise. A new patient was seen in the physician’s office for a cough, sore throat, and fever. The physician documents the total time as 35 minutes. An established patient with complaints of chest pain saw Dr. Rao in his office. Dr. Rao decided to admit the patient to Central Hospital on March 2 under observation status. She obtained a comprehensive history and physician examination. The patient revelated that he had been under emotional stress in the past month related to his recent divorce and that test revealed no coronary artery disease. Dr. Rao performed medical decision-making of moderate complexity and determined the origin of the pain to be musculoskeletal secondary to stress. She discharged the patient on March 2 and recommended that he joins a stress management group. An established patient complaining of a cough, generalized weakness, joint aches and a sore throat was seen in an intermediate care facility (rest home). She stated that the sore throat started a week ago and there had been some green productive sputum with her cough. The patient noted that several of her coworkers had the flu. Examination revealed the following: T: 100.5. B/P 125/68, P 76, tired appearance. HEENT: normal. PERLA: no bruits. TMs clear, nares were erythematous. Oropharynx mildly inflamed. Lungs: bronchial breath sounds, some coarseness in upper airways. Heart: regular rate and rhythm. Abdomen: soft, no obvious masses; bowl sounds normal. Assessment #1 Influenza, #2 Bronchitis. Prescribed Tamiflu and Z-pack. The documentation supported a detailed history, expanded problem focused examination, and moderate-complexity decision-making. In the initial skilled nursing facility visit, Dr. Reynolds saw a new patient complaining of diarrhea as well as nausea, vomiting, and crampy, lower abdominal pain. Dr. Reynolds provided a detailed history and examination, and medical decision-making of moderate complexity. An 88-year-old patient is having trouble with her vision and is confused about her medications. The physician conducts a home visit for this established patient and documents a detailed interval history and examination with medical decision-making at a high level of complexity. SCIENCE HEALTH SCIENCE NURSING NUR 152

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