[Expert Solution]: Using the E/M Medical Decision Making Grid,…

Using the E/M Medical Decision Making Grid, code the following emergency department visit and provide the following answers for this coding scenario: 1) E/M Emergency Department CPT Code 2) Procedure CPT Code 2) Number and Complexity of Problems Addressed (Minimal, Low, Moderate, or High) 3) Amount and/or Complexity of Data to be Reviewed and Analyzed (Minimal, Limited, Moderate, or Extensive) 4) Risk of Complications and/or Morbidity or Mortality of Patient Management (Minimal, Low, Moderate, or High) CODING SCENARIO: Chief Complaint: Facial injury HPI: 14-year-old male presents to the emergency room with facial injury. He was tubing down a hill nearby when he struck the right side of his face, not entirely clear what he struck his face on, although likely the ice/snow. LOC for likely “a few seconds”. Some mild amnesia surrounding event, event occurred several hours ago earlier today. He went home and had pain to his face. No vision changes per se, no other complaint. No neck pain, no back pain, no abdominal pain. He is up to date on his tetanus immunizations. PMH: Unremarkable Social: Never smoker, no alcohol use Family History: Unremarkable Review of Systems: Constitutional: Negative. Neck: Negative for neck pain and neck stiffness. Eyes: Positive for pain and redness. Negative for photophobia, discharge, itching and visual disturbance. Respiratory: Negative. Cardiovascular: Negative. Gastrointestinal: Positive for nausea. Negative for vomiting and abdominal pain. Skin: Positive for bruising. Neurological: Positive for syncope and headaches. Negative for tremors, seizures, facial asymmetry, weakness and numbness. All other systems reviewed and are negative. Physical Exam: Vital signs: BP 123/74 | Pulse 61 | Temp(Src) 97.6 deg F (36.4 deg C) (Oral) | Resp 16 | Ht 6′ 2″ (1.88 m) | Wt 75.297 kg (166 lb) | BMI 21.31 kg/m2 | SpO2 100% Constitutional: He is oriented to person, place, and time. He appears well-developed and well-nourished. Ambulatory, no obvious distress. Oriented appropriately, conversational. Mother at bedside. HEENT: Oropharynx is clear and moist. No oropharyngeal exudate. There is a 1.5 non-gaping, linear laceration to right eyebrow at lateral aspect. Mild soft-tissue swelling surrounding right eye. No facial crepitance, no septal hematoma. TMs clear bilaterally. No Raccoon eyes, no mastoid tenderness to palpation. Small subconjunctival hemorrhage at right temporal sclera. Visual fields intact and symmetrical to both eyes, nasal and temporal fields. No hyphema, no pain with EOM, no proptosis, no light sensitivity, PERRL. Neck: Normal range of motion. Neck supple. No pain with ROM in all planes, no pain with axial loading. No external evidence of trauma, supple. Cardiovascular: Normal rate, regular rhythm, normal heart sounds and intact distal pulses. Exam reveals no friction rub. No murmur heard. Pulmonary/Chest: Effort normal and breath sounds normal. No respiratory distress. He has no wheezes. He has no rales. Abdominal: Soft. He exhibits no distension. There is no tenderness. There is no rebound. No external evidence of trauma. Neurological: Alert and oriented to person, place, and time. He displays no tremor. No cranial nerve deficit or sensory deficit. Exhibits normal muscle tone. Coordination and gait normal. GCS eye subscore is 4. GCS verbal subscore is 5. GCS motor subscore is 6. Skin: Warm and dry. He is not diaphoretic. Medical Decision Making: Patient came in with blunt head trauma and minor facial laceration. Examination shows normal vital signs, intact vision, intact neurologic examination, ambulatory with minimal facial pain, no associated symptoms. Examination suspicious for orbital/facial bone injury, (+) LOC with unclear mechanism makes CT imaging warranted. CT shows several fractures regarding right orbit, CT head otherwise unremarkable. Patient re-assessed several times, visual acuity unremarkable upon arrival and throughout ED stay. Pain medications declined by patient. I spoke with the ENT on call, recommendation are for sinus fracture precautions, close follow-up. This was explained to the patient and mother at length. Indications for returning to ED discussed, mother expresses agreement and is comfortable with plan. At time of disposition planning after extended ED stay, patient remained ambulatory, conversational, lucid, no apparent distress. Post-concussive symptoms described, they have an appointment with primary care provider tomorrow and with ENT next Tuesday. Procedure: Wound anesthetized with 2 cc’s 1% lidocaine. Wound cleansed with sterile dressing and water. Wound edges re-approximated with 3 sutures of 6-0 fast absorbing gut suture, simple interrupted. Antibiotic ointment and dressing applied. Wound care instructions provided. Condition on disposition: Stable