A 74-year-old patient is referred by a third-party payer for…

A 74-year-old patient is referred by a third-party payer for a second opinion regarding osteoarthritis in the right knee. The consultant saw the patient in his office at the insurance company’s request. He performed a comprehensive H&P and moderate MDM. The physician reviewed x-ray films and numerous records brought by the patient from the family practitioner. The consultant agreed with the family physician that a total knee replacement was needed.

Jeff Johnson, an established patient, is seen in the hospita…

Jeff Johnson, an established patient, is seen in the hospital by his physician on day two of his hospital stay. Mr. Johnson had been previously admitted with chronic obstructive asthma and has been undergoing extensive respiratory therapy over the past 24 hours. The physician performs a detailed H&P. The possibility of pneumonia complicating the asthma must be considered. Given the fact that the patient’s respiratory condition is still unstable, the physician’s MDM reflects a high complexity. Code day two of the patient’s hospital stay.

A patient in the emergency department has a temperature of 1…

A patient in the emergency department has a temperature of 105 F and is in acute respiratory distress. Symptoms include shortness of breath, chest pain, and gasping. The physician documents that he is unable to obtain a history or perform a physical exam because the patient’s condition is critical.