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Roger Forshay, a 75-year-old male, has been living at Franklin…

  1. Roger Forshay, a 75-year-old male, has been living at Franklin Assisted Living Facility for 6 months. Dr. Hanner, his primary physician since he moved in, comes in today to see Roger because of a complaint of leg pain. Dr. Hanner documents a problem-focused interval history, an expanded problem-focused exam, and MDM of moderate complexity. What E/M code would be used to bill. 
  2. Dr. Samuels asked Dr. Weldon to provide a second opinion on Burton Conner, a 17-year-old male. Burton’s pulmonary specialist, Dr. Samuels, wants to perform a lung transplant because of his diagnosis of cystic fibrosis. Dr. Weldon examined Burton’s respiratory system in his hospital room, received the x-rays ordered by Dr. Samuels, and drafted a report agreeing that Dr. Samuels should perform the surgery. What E/M code would be used to bill. 
  3. Barbara Bracken brought her daughter, Darlene, a 5-year-old female, to her pediatrician’s office after they had attended a friend’s birthday party in the park. After a cursory examination, Dr. Jackson removed a jellybean (foreign body) from Darlene’s nose. Then Dr. Jackson removed a splinter (foreign body) from Darlene’s hand. What two CPT codes and/or modifier is used for this encounter. 
  4. Dr. Vitali excised a lesion that measured 2.0 cm by 1.0 cm, with 0.2cm margins all around, from Benita Corraldo’s neck. The pathology report confirmed that the lesion was benign. What is the range used to bill? 
  5. Benjamin Zabine, a 17-year-old male, plays basketball on his high school team. While practicing in his driveway, he fell and fractured the shaft of his tibia. Dr. Casson, the orthopedist on duty at the emergency room, (trauma) is able to use a percutaneous fixation using pins. 
  6. Anita Julianne, a 37-year-old female, is admitted today for the surgical removal of a kidney stone. The stone was too big for her to pass, so Dr. Hernandez decided to remove it surgically. The nephrolithotomy, with complete removal of the calculus, went as planned, and Anita tolerated the entire procedure well. 

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