Reference no: EM133841209

Problem

Ms. Smith was admitted to observation at a local hospital. The physician performs a medically appropriate history and exam on the initial visit, and the medical decision is moderate complexity. What CPT code would be reported for the initial observation?

Ms. Smith's physician sees her during hospital rounds. He performs a medically appropriate history and exam, and determines Ms. Smith is improving. He decides Ms. Smith needs to remain under observation for one more day, and documents low medical decision making. Get the instant assignment help.

Ms. Smith's physician sees her after his clinic hours. He performs a medically appropriate history and exam, and determines Ms. Smith has improved enough to be discharged home. He spent 25 minutes with her and her husband reviewing the lab work performed during her stay, discussed the need for proper diet and exercise changes, and ordered physical therapy and prescription medication. Then he spent an additional 20 minutes preparing the discharge papers.

What CPT code would be reported for the discharge encounter?