(Solved): Exercise \#1 - Check Your Understanding Documentation of patient history The following documentatio ...

Exercise \#1 - Check Your Understanding Documentation of patient history The following documentation represents a history for a patient encounter. Identify the parts of the history using the terms listed. The first one is done for you. 1. Social history 2. Chief complaint 3. Past history 4. Severity 5. Family history 6. Quality 7. Review of systems 8. Associated signs and symptoms Beth presents today with a cough and nasal congestion (1) $2$ She says she has an extremely painful (2) _. nonproductive cough (3) She has had a fever, which the patient states ran between 101 and 102 over the last few days (4) . Her sister is just getting over strep throat, but no other family members are ill (5) Beth says she has never been hospitalized and has no drug allergies (6) . She has no ear pain, no nausea, no vomiting, and no change in bowel habits (7) Beth is not a smoker, does not consume alcohol, and is not a recreational drug user (8) evaluation and Management Coding Using a CPT manual, choose the correct code for the level of E/M service rendered (9921199215), based on the following examination and medical decision making given \& 1. Detailed examination/moderate medical decision making 2. Problem-focused examination/straightforward medical decision making 3. Expanded problem-focused examination/low-complexity medical decision making 4. Detailed examination/lowcomplexity medical decision making 5 . Comprehensive examination/high-complexity medical decision making 2. Dr. Smith saw his patient on the medical unit of the hospital. This was a follow-up visit from the day before. The history and examination were expanded problem-focused, and medical decision making was of a moderate level. The code chosen for this visit is 3. Dr. Cary sent Ms. Kelley to the hospital from his office. He saw her later that day, when he added to the information he had gathered at his office. The history and examination were comprehensive. The medical decision making was of high complexity. The level of service chosen for this hospital visit is 4. Sandy was being discharged from the hospital. The doctor gave her a brief examination, discharge instructions, and prescriptions for medications. He talked to her family about follow-up care. This all took approximately 25 minutes. The correct code for this hospital visit is 5. Mr. Alexander was admitted to the hospital two days ago by Dr. Simmons. Dr. Simmons had been seeing Mr. Alexander each day. Today Dr. Simmons documented an expanded problem-focused interval history and an examination of the same level. Because a new problem developed, medical decision making was of a moderate level. The level of service chosen for this hospital