MDC 240 Level of EM Medical Decision Making Paper.
MDC 240 Level of EM Medical Decision Making Paper.
Reason for the Encounter/Chief Complaint:
The patient was brought by to the ER by his wife after being shot in the head and leg by a random shooter while he was playing basketball in the park by his home. In the ER, the physician provided critical care services for 150 minutes. During this time the physician reviewed the patient’s chest X-ray, ECG, pulse oximetry, cardiac output measurements and blood gas results on the EHR, and an Endotracheal intubation was done before transferring the patient to ICU.
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PART II (TITLE THIS PART II):
This is the part where you use the attatchment below:
Continue on the training word document and include another example: You will use Patient Case Number OPOV62-Capelton, Estel as a coding example. You will need to:
Discuss the four levels of the medical decision-making process and the management options.
Code this case for accuracy and explain your process using ICD-10-CM and CPT E/M codes.
/7/2021 OPOV62CapeltonEstel Outpatient Office Visit Patient Case Number: OPOV62-Capelton, Estel Patient Name: Estel Capleton DOB: 06-07-52 Sex: F Date of Service: 10-22-XX Physician: Pedro Hernandez, MD Chief Complaint: New patient is here for hospital follow up for large ovarian mass that looks malignant History of Present Illness: The patient states that she noticed moderate to severe pain left lower abdomen for about 1 week. This got worse and went to ER and was noted to have very large ovarian cyst, suspicious for cancer. Today she says she has pain of about 8/10 particularly when she moves and lays on her left side. She feels that her pain is less when she lays on her right side. She has nausea, no vomiting and has no appetite. She had a little constipation, but now more like diarrhea. Review of Systems Constitutional: anorexia, but negative. Cardiovascular: negative. Respiratory: negative. Gastrointestinal: abdominal pain and vomiting. Genitourinary: negative. Medications: Folic acid, Omeprazole, Salsalate Past Medical History: Noncontributory Surgical History: Tubal ligation Allergy: NKDA Vitals Temperature Heart Rate Respiration BP Height Weight BMI LMP 98.5 80 16 120/80 5’2 195 35.7 Age 55 https://myahima.brightspace.com/content/enforced/6681-VLAB_STUDENTPROTO/PatientCaseScenarios/Outpatient_Office_Visit/OPOV62CapeltonE… 1/2 6/7/2021 OPOV62CapeltonEstel Physical Examination Constitutional General appearance: Normal. Abdomen Abnormal. obese. A cystic mass noted in the mid abdomen and appears mildly tender. Psychiatric Orientation to person, place, and time: Normal. Mood and affect: Normal. Results/Data: Reviewed from ER- has huge complex ovarian cyst, suspicious for cancer. Assessment: 1. Ovarian cyst- patient was given a rx for Norco for chronic pain. Plan for laparotomy and possible staging discussed based on frozen section. Electronically Signed By: Pedro Hernandez, MD Copyright © 2020 by The American Health Information Management Association. All Rights Reserved. https://myahima.brightspace.com/content/enforced/6681-VLAB_STUDENTPROTO/PatientCaseScenarios/Outpatient_Office_Visit/OPOV62CapeltonE… 2/2