A physician performs an E/M service in an office or other outpatient setting for a new patient and documents a detailed history, a detailed physical examination, and a low medical decision making. However, the physician also documents that he spent 45 minutes in face-to-face counseling with the patient and his wife about his presenting problem and plan of care. What is the MOST appropriate overall level for the E/M service?
A. Level 2
B. Level 3
C. Level 4
D. Level 5
Question 2
Which of the following are the BEST example of counseling and/or coordination of care?
A. A physician discusses the presenting problem, prognosis and treatment plan with the patient in the patient's hospital room
B. A physician independently reviews the radiology image in the presence of the patient in the clinic exam room, explaining the presenting problem in relation to the radiology results
C. A physician orders explains the necessary diagnostic testing and need for a second opinion with the patient's family just outside the patient's room while the patient is sleeping
D. All of the above
The nurse needs to note the source of the patient health history
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