A 47-year-old woman presents to her regular physician with a chief complaint of painful urination and dizziness. The woman has been living in a different state for five years; this is her first visit after returning to the area. The physician documents a comprehensive history, a detailed 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 2
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
Which of the following BEST defines a presenting problem of minimal severity?
A. A problem that, if untreated, has a high risk of significant morbidity or mortality or an extreme, negative impact on the patient's health or ability to function
B. A problem that may not require the presence of a physician, but is provided under the supervision of a physician
C. A problem that has a specific course and is not chronic in nature, and is not likely to permanently impact the patient's long term health, and poses little risk of mortality without treatment
D. A problem that, if untreated, may lead to increased morbidity and may even significantly impact the patient's health or ability to function
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Example of a Physician’s Prescription