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
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