Predictive Value - answerLikelihood person has disease
3 key components that determine risk-based E&M codes - answerHistory
Physical
Medical Decision Making
Complexity of a visit is based on three criteria (aka MDM) - answerRisk
Data
Diagnosis
13. Identify the 3 components required in determining an outpatient, office visit E&M
code - answerPlace of service
Type of service (consult, office visit, hospital admit)
Pt status (new vs established)
most common type of pathogen responsible for acute gastroenteritis - answerViral:
Norovirus (Leading cause for adults)
-Rotovirus (Leading cause for peds up to 2 years old)
IBS - answerdisorder of bowel function not from anatomic abnormality
-constipation, diarrhea, bloating, urgency w/ diarrhea
-NOT assoc w/ serious medical consequences, IBD or CA
+S/S: result from disordered sensation or abnormal function of the small and large
bowel
IBD - answerchronic immunologic disease that manifests in intestinal inflammation
- UC/CD
UC - answerthe mucosal surface of the colon is inflamed and ultimately results in
friability, erosions, and bleeding.
, - Most common in recto-sigmoid colon. Can involve entire colon
- Pain in RLQ
Chrons - answerthe inflammation extends deeper into the intestinal wall and can involve
all or any layer of the bowel wall and any portion of the GI tract from the mouth to the
anus.
- Skipped lesions
- Pain in LLQ
Diverticulitis - answerSymptoms: LLQ pain/ tenderness, fever, N/V/D
Need imaging especially if perforation or peritonitis is suspected; free air = perforation;
patient may have ileus, small or large bowel obstruction
Can use plain x-ray
CT or barium enema are preferred
CT with contrast is more sensitive and accurate
Barrett's Esophagus - answerAfter repeated exposure to gastric contents, inflammation
of the esophageal mucosa becomes chronic.
· Blood flow increases, erosion occurs
·Premalignant tissue
·Increased risk for development of esophageal adenocarcinoma
· Fibrosis and scarring during healing of erosions; leads to strictures
Sensorineural Hearing Loss - answerResults from deterioration of cochlea
-Loss of hair cells form the organ of Corti
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