A 17-year-old man presents to his regular pediatrician for an annual physical. During the course of the visit, the physician notices an amphoric breath sound
Further collection of history reveals that the patient has had a persistent and productive cough that began last week. Patient remembers eating pistachio nuts while playing video games with friends and distinctly remembers choking. After recovering from the episode, video game play resumed, and he thought nothing of it. Physical examination: Reveals distinct amphoric breath sounds accompanied by right-sided wheezes. Assessment: Probable foreign-body airway obstruction of right bronchi. Plan: Recommend bronchoscopy to identify and, if necessary, remove foreign body. Physician documents a detailed history, expanded problem-focused physical examination, and moderate medical decision making. Other than this presenting problem, physician performs an age and gender appropriate history, physical examination, and risk factor counseling pertinent to a young man—specifically, good driving habits, safe sexual practices or abstinence, and identification of alcohol or drug use. Which of the following best reflects the service(s) provided?
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a. One code: office or other outpatient service, new patient, level 3
b. One code: preventive medicine, established patient
c. Two separate codes: (1) preventive medicine, established patient, and (2) office or other outpatient; established patient, level 4
d. Two separate codes: (1) preventive medicine, new patient, and (2) office or other outpatient service, new patient, level 3
c) Two separate codes: (1) preventive medicine, established patient, and (2) office or other outpatient; established patient, level 4
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