Question

After reading scenario answer the questions:

1.identify the history type:comprehensive, problem focused, detailed or comprehensivie?

2. identify the subcategory of the E/M level?(new patient or established patient)

3. what code should be reported?(99202,99221,99204,99201)

4. identify the medical decision making?(straight forward, low complexity, moderate complexity, high complexity)

5. identify the elements of PFSH( past history, family history, social history, all of them)

6. identify the level of PFSH( complete, problem pertinent)

7. what e/m category this would fall under?(inapatient services,, office or other outpatient services)

8. identify the chief complaint(Borderline glucose level, hypertension, CHF, Astha)

9. identify the problem pertinent body system reviewed( endocrine system, cardiovascular system, respiratory system, urinary system)

10. identify the HPI level (brief, extended)

Mr Kim is a 35 year old welder by trade who was found to have borderline glucose levels during a hospital stay 1 month ago.The levels were higher after meals but never exceeded 200mg/dL.The patient thinks he might have experienced some frequent urination, but that could be from increased fluid intake.Since his hospital stay, the patient has been concerned about his blood sugar and has started walking 20 minutes at least 5 days/week, and reducing fis caloric intake.

Mr .Kim reports no recent weight changes or changes in appetite .His vision has returned to normal since his corneal transplant .He has not noticed any recent cuts or bruises that are slow to heal.No extremity tingling or numbness.No oral infections.No skin infections .No bladder infections .Normal bowel movements .No shortness of breath,no chest pains.

Patient reports his knees hurt from time to time from remote history of athletics , but pain is controlled with ibuprofen.No depression,slight anxiety concerning healing eye trauma.No other current endocrine symptoms or disease.Patient is immunosuppressed due to the corneal transplant and reports his medication is preventing rejection.

No other medications.Patient reports paternal grandfather developed type II diabetes over 60.No other diabetic history.Patient is a welder and has recently started an exercise routine.

Exam:

Head:normocephalic,atraumatic

Neck:supple,trachea midline,no lymphadenopsathy

Eyes:grossly normal

ENMT:mucous membranes pink

Cardiovascular:RRR

Respiratory:clear breath sounds bilateral

GI:Positive bowel sounds,no organomegaly

GU:external genitalia normal, no hernias palpated

Extremities:full ROM in all four extremities; positive reflexes and strength x4; no skin changes noted

Neuro:cranial nerves II-XII normal; patient is oriented X3

Data reviewed:

Patient had a fasting blood sugar 3 days ago 90 mg/DL, which is high normal.

Cholesterol also elevated but WNL

Other labs were normal.

Assessment and plan:

Mr.Kim had recent elevated blood sugars, but latest test shows high normal.At this time I would not consider him diabetic or prediabetic, given his absence of symptoms and transient blood sugar levels.Mr.Kim should continue new diet and exercise habits.I gave him a pamphlet today on healthy eating.Mr.Kim should see me every 6 months to monitor his progress and hopefully avoid any disease process.Should his blood sugars start to increase , we will revisit his diagnosis and treatment.I considered multiple treatment options and reviewed a moderate amount of data.At this point ,I think Mr.Kim has a moderate risk of developing type II diabetes at some point in the future,   

Answer 1

Answer to 1st question:

Patient history type is Comprehensive

Answer to 2nd question:

Subcategory of the E/M level is Established patient

Answer to 3rd question:

The code should be reported is 99221 . this code is used for inpatient services .

Answer to 4th question:

The medical decision making is Moderate complexity

Answer to 5th question:

The elements of PFSH are PAST history -- The glucose levels are higher after meals not more than 200mg/dL a month ago and fasting blood sugar 3 days ago 90 mg/DL, which is high normal .The pain in knees is controlled with ibuprofen medication.

Family history -- Type 2 diabetes is in his paternal grandfather.

Social history is walking 20 minutes at least 5 days/week  

Answer to 6th question:

The level of PFSH is Complete because if reviewing two or all three of PFSH history areas based on E/M service.

Answer to 7th question:

This would fall under the in patient services of  E/M category.

Answer to 8th question:

The chief complaint is related to Border glucose level.

Answer to 9th question:

The problem pertinent body system reviewed relate to the problem identified in the HPI. in respiratory system , it is bilateral breath sounds.

The cardiovascular system shows RRR means normal regular heart rate and  rhythm.

No symptoms present in the endocrine system.

The Genitourinary tract (GU) does not shows abnormal symptoms and normal external genitalia , and no plapations seen in Hernia. So no symptoms of organ dysfunction.

Answer to 10th question:

tHE HPI level is Extended HPI ( History of present illness).