A 38-year-old man presents his regular clinic for a same day appointment to address his severe abdominal pain, diarrhea, and headache. His regular physician is not available and the new physician sees the patient. The physician documents a detailed history, expanded problem focused physical examination, and a moderate medical decision making. What is the MOST appropriate overall level for the E/M service?
A. Office or other outpatient site, new patient Level 4
B. Office or other outpatient site, established patient Level 3
C. Office or other outpatient site, new patient, Level 3
D. Office or other outpatient site, established patient, Level 4
Question 2
During a new patient office visit, the physician documents an expanded problem focused history and physical examination for a patient with abdominal pain, diarrhea, difficulty sleeping, and headaches; history reveals the patient drinks in excess of five cups of coffee daily. Medical decision making is low. However, because the patient is so concerned about the abdominal pain and diarrhea, the physician spends a total of 45 minutes counseling the patient on proper dietary and bowel habits, stress reduction, and recommendations for limitation of caffeine intake. What is the MOST appropriate overall level for the E/M service?
A. Office or other outpatient site, established patient, Level 4
B. Office or other outpatient site, established patient Level 3
C. Office or other outpatient site, new patient Level 4
D. Office or other outpatient site, new patient, Level 3
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