established patient quizlet
Who is not a documenter of the patient chart? NOTE: A code of 52648 is needed for the laser vaporization of the prostate. CCW 6.7. An established patient is anyone who has previously received professional services from the physician or another physician of the same specialty who belongs to the group practice. What is the CPT code. catch size and prevent fishery collapse. Note: The information obtained from this Noridian website application is as current as possible. Each question is worth 2 points. 60650 O: Rectal examination reveals multiple soft external hemorrhoids. Code 33977 would only be used if the physician was removing a ventricular assist device. ICD-10-CM Code Answer 2: Code in proper sequence. Code in proper sequence. Assign the correct diagnosis codes for a 29-year-old patient with deep third-degree burns of the chest and right leg. A 37 year-old female is seen in the clinic for follow-up of lower extremity swelling. What diagnosis codes are assigned for this case? The doctrine of professional discretion pertains to medical record keeping. Established Patient Individual who has received any professional services, E/M service or other face-to-face service (e.g., surgical procedure) from this provider or another provider (same specialty or subspecialty) in the same group practice within the previous three years. abs0s1s0s1s2s1s2s3s2s3s3s3\begin{aligned} Which of the following solutions can act as a buffer: 1. Which of the following patients is an established patient? At the end of 2013, the management of Central Appliance analyzes the appliances sold within the preceding 12 months. X-ray is normal In which situation is a patient not considered established to the rendering physician? What CPT code(s) is/are reported for this visit? What is the probability that the first process has an event before the second process does? Use the guidelines of this section to sketch the curve. The patient is still running above-normal glucose levels, so the physician decides to adjust the patient's insulin. CPT Code Answer 1. She has Type 2 diabetes, which has been in good control now. This 25-year-old woman has been treated for Crohn's disease of the small intestine since 18 years of age. Ordered tests or procedures can be discussed and scheduled The patient is an established patient with Dr. A. but she has not been seen by Dr. B. before. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT. Medical Assisting - Chapter 9 Appointment Sch, MA Ch. It is sent to Dr. Smith, a cardiologist, to read and interpret. Policy must exist and be enforced \text{Warranty Liability}&\$ 6,000\\ \end{array} Patient is improving and a pulmonary consultation has been requested. It classifies all appliances still covered by warranty as follows: those sold on or before June 30 (more than six months old), those sold after June 30 but on or before November 30 (more than one month but less than six months old), and those sold on or after December 1. 1. A medical bag (doctor's bag, physician's bag) is a portable bag used by a physician or other medical professional to transport medical supplies and medicine. Unauthorized or improper use of this system is prohibited and may result in disciplinary action and/or civil and criminal penalties. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2)(June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a)(June 1995) and DFARS 227.7202-3(a)June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department Federal procurements. What does the doctrine of professional discretion protect? The responsibility for the content of this file/product is with Noridian Healthcare Solutions or the CMS and no endorsement by the AMA is intended or implied. How is this reported in ICD-10-CM? It is up to the discretion of the physician whether or not to allow all patients access to their medical records. What CPT code(s) would this physician report? This code includes control of postoperative bleeding, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy. Which of the following is the correct code assignment? You can erase, text, sign or highlight through your choice. ICD-10-CM and CPT Code(s): Code in proper sequence. Code in proper sequence. What subsection is used to report the ED visit? Assign the codes, including E/M codes and laboratory codes, for this case. Offer patient first available appointment giving a choice between two dates and times Booking two patients at once to see same physician/time is sometimes used to work in a patient with an acute illness or injury when there are no open appointments. Dr. H. Art spends another hour stabilizing the patient and performing CPR. You, your employees and agents are authorized to use CPT only as contained in the following authorized materials: Local Coverage Determinations (LCDs), training material, publications, and Medicare guidelines, internally within your organization within the United States for the sole use by yourself, employees and agents. Then think about the Repeat appointment date and time and thank the patient for calling In old Hawaii, certain This cookie is set by GDPR Cookie Consent plugin. The D0180 code can be used on established patients who have risk factors and require a comprehensive periodontal evaluation. 1,14,19,116,125,;S11, \frac{1}{4}, \frac{1}{9}, \frac{1}{16}, \frac{1}{25}, \ldots ; S_11,41,91,161,251,;S1 and S5S_5S5. ICD-10-CM and CPT Code(s): Code in proper sequence. In short, a patient is established if the same provider, or any provider of the same specialty and subspecialty who belongs to the same group practice, has seen that patient for a face-to-face service within the past 36 months. There is also a section of the jejunum that is very inflamed. Be understanding when possible, but do not let a patient take advantage of physician's time Dr. Smith, a cardiologist, sees a patient at "Clinic B." Patient is taken to surgery immediately. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. The provider performs the physical. A 10 sq cm epidermal autograft to the face from the back. CCW 6.108. An infant is born six weeks premature in rural Arizona and the pediatrician in attendance intubates the child and administers surfactant in the ET tube while waiting in the ER for the air ambulance. Patient will be scheduled for a sleep study. The ED provider makes a notation the 1 hour does not include the time for the other separate billable services. Options for first payment should be discussed If this is a U.S. Government information system, CMS maintains ownership and responsibility for its computer systems. End Users do not act for or on behalf of the CMS. Modifiers are not used in this example. This system is provided for Government authorized use only. How is carcinoma of the oral cavity and lower lip coded? CCW 6.52. Although, Dr. Smith is no longer at "Clinic A," the patient is still considered an established patient for Dr. Jones as Dr. Smith and Dr. Jones are of the same specialty. The use of the information system establishes user's consent to any and all monitoring and recording of their activities. A: Multiple soft, thrombosed external hemorrhoids. fishing grounds near shore could be used only by certain individuals. What diagnosis codes are assigned? A combination of both male and female personality traits is called _____. The CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material. \text{All Other Liability and Shareholders Equity Accounts}&\underline{204,000}\\ Medical history 3. CCW 6.108. FOURTH EDITION. A 75-year-old established patient presents for his annual physical exam. The chief complaint is a concise statement describing the symptom, problem, condition, diagnosis, physician-recommended return, or other reason for a medical encounter. 59074 This is sometimes called the "office visit" code. Patients who don't meet that definition are new patients. B. a patient who has been seen by the same physician over time, the same group of physicians over time, or been seen in the office within the last two years. She is complaining of low back pain and no tingling or numbness. CCW 6.110. \textbf{Balance Sheet Excerpts}&\textbf{2012}\\ A patient is diagnosed as having both acute and chronic tonsillitis. A 3 year-old critically ill child is admitted to the PICU from the ER with respiratory failure due to an exacerbation of asthma not manageable in the ER. Is a physicians obligation to their patient based on trust and confidence? The physician takes the blood pressure and references the patient's last three glucose tests. CCW 6.110. CCW 6.62. No additional codes are needed. 99211. Note each cancellation in patients' medical record, with reason if possible, Some patients do not realize importance of keeping appointments Commercial Photography: How To Get The Right Shots And Be Successful, Nikon Coolpix P510 Review: Helps You Take Cool Snaps, 15 Tips, Tricks and Shortcuts for your Android Marshmallow, Technological Advancements: How Technology Has Changed Our Lives (In A Bad Way), 15 Tips, Tricks and Shortcuts for your Android Lollipop, Awe-Inspiring Android Apps Fabulous Five, IM Graphics Plugin Review: You Dont Need A Graphic Designer, 20 Best free fitness apps for Android devices. Second no-show, warn patient; third time, consider dropping the patient. A 10 year-old girl is scheduled for her yearly physical with her pediatrician. He gets lightheaded and dizzy and goes to the local hospital Emergency Department. Code in proper sequence. ICD-10-CM Code Answer 2: Code in proper sequence. For office or other outpatient services, if the physician's or other qualified health professional's time is spent in the supervision of clinical staff who perform the face-to-face services of the encounter, use code 99211. From this analysis, management estimates that $5,000 of repairs will still have to be made in 2014 on the appliances sold in 2013. Indeed, there is a clear consensus that quality health services across the world should be effective, safe and people-centred. The cookie is set by GDPR cookie consent to record the user consent for the cookies in the category "Functional". True or False?. The following table shows summary data and financial statement excerpts for Central Appliance for the end of 2012 and for some of the events during 2013. BalanceSheetExcerptsMerchandiseInventoryAllOtherAssetAccountsTotalAssetsWarrantyLiabilityAllOtherLiabilityandShareholdersEquityAccountsTotalLiabilitiesandShareholdersEquityIncomeStatementExcerptsSalesRevenueWarrantyExpenseEndof2012$100,000110,000$210,000$6,000204,000$210,0002013$1,000,000?2012$800,00018,000. 5. You'll get a detailed solution from a subject matter expert that helps you learn core concepts. face-to-face services from a physician/qualified healthcare professional, or another physician/qualified healthcare professional of the exact same specialty and . established patients Scheduling for Established Patients: In Person Most return appointments are arranged when patient is leaving office Have all patients stop by front desk before leaving in case information is needed or outside scheduling must be done Ordered tests or procedures can be discussed and scheduled Dr. Smith's NPI is used to track if the patient has been seen within the previous 3-years. The physician was called to the hospital floor for the medical management of a 56 year-old patient admitted one day ago with aspiration pneumonia and COPD. If a patient was seen by a physician in a clinic and sometime during the 3-year period was seen again by that same physician at the same clinic, at another clinic, or in this physician's private practice, this is still an established patient situation. This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. \hline The provider completed an age / gender appropriate history, exam, and provided anticipatory guidance. The provider starts continuous bronchodilator therapy and pharmacologic support along with cardiovascular monitoring and possible mechanical ventilation support. Discuss specifically how these systems provide incentives for conservation. CCW 6.22. (a) For how long ttt was the payload off the ground? Before you can enter the Noridian Medicare site, please read and accept an agreement to abide by the copyright rules regarding the information you find within this site. A 45 year old male presents to the ER, where an open fracture for the left radius is diagnosed. BY CLICKING ABOVE ON THE LINK LABELED "I Accept", YOU HEREBY ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD AND AGREED TO ALL TERMS AND CONDITIONS SET FORTH IN THESE AGREEMENTS. A patient who has been formally admitted to a health care facility. Finally. A 48-year-old female seen 1 year ago for a routine physical. ICD-10-CM Code Answer 5: Code in proper sequence. This has resolved with diuretics; it may be secondary to problem #2. Private residence considered: a private home, an apartment, or town home. The cookies is used to store the user consent for the cookies in the category "Necessary". If f(c)=0f^{\prime}(c)=0f(c)=0 there is a maximum or minimum at x = c. Write each function value in terms of the cofunction of a complementary angle. CCW 6.109. An established patient is seen for management of diabetes and hypothyroidism and the physician spends equal time on each diagnosis. The MDM is straightforward. They spend 45 minutes talking with Dr. Smith. The AMA is a third-party beneficiary to this license. NOTE: A code of 69799 (unlisted procedure, middle ear) should be utilized for patient who requires an eustachian tube catheterization. If patient is a referral, you may need to call referring physician's office for additional information before appointment To obtain comprehensive knowledge about the UB-04 codes, the Official UB-04 Data Specification Manual is available for purchase on the American Hospital Association Online Store. 3. No fee schedules, basic unit, relative values or related listings are included in CPT. An established patient was seen today for a level 2 visit. \hline Patient complains of headache and blurry vision for the past 3 days. CPT Code Answer 3: Code in proper sequence. These materials contain Current Dental Terminology, (CDT), copyright 2020 American Dental Association (ADA). Examination reveals that the existing gastrostomy site is infected. ", Dr. Smith leaves "Clinic A" and joins "Clinic B." When is a Medicare patient a new patient? A fetal thoracentesis was performed. Subsequently, it was determined that the patient would require a C-section for cephalopelvic disproportion because of obstructed labor. Patient was admitted with a cystocele and rectocele. Concurrent care is the provision of similar services (eg, hospital visits) to the same patient by more than one physician or other qualified health care professional on the same day. Subjective: 6 year-old girl twisted her arm on the playground. CCW 6.2. \text{Total Assets}&\underline{\underline{\$210,000}}\\ 2. an expected event that throws a plan into disorder; an interruption that prevents a system or process from continuing as usual or as expected. 4. What activities are included in physician's time? CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CDT. These cookies help provide information on metrics the number of visitors, bounce rate, traffic source, etc. A patient sees Dr. Smith, a cardiologist, for follow up care at "Clinic A. This is the first time he has been to this hospital. 1. Patient came in for excision of a middle ear lesion. An expanded problem focused exam was performed. On this page, view the below information. You acknowledge that the AMA holds all copyright, trademark, and other rights in CPT. She requested no medication. Find the indicated partial sums for the sequence. Patient is admitted for contact laser vaporization of the prostate. She is being seen now for extreme pain, which on x-ray shows small bowel obstruction. Code 33404 is a necessary part of the main procedure designated by code 33975, so it would be incorrect to use both codes. CCW 6.52. A 90 year-old female was admitted this morning from observation status for chest pain to r/o angina. Dr. H. Art is in the ER to direct the activities of the paramedics. CCW 6.41. What is the definition of a new patient in CPT? You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. NOTE: When multiple wounds are repaired, you should add together the lengths of those in the same classification and from all anatomic sites that are grouped together into the same code (add the length of the two lesions together 5 cm + 2.7 cm = 7.7 cm total). Can a practice have more than one patient ID number? For U.S. Government and other information systems, information accessed through the computer system is confidential and for authorized users only. Any questions pertaining to the license or use of the CPT must be addressed to the AMA. ICD-10-CM Code Answer 2: Code in proper sequence. Established Patient (EP) Patient who has received professional services from a provider (or another provider with the same specialty in the same practice) within the past three years. No portion of the AHA copyrighted materials contained within this publication may be copied without the express written consent of the AHA. This section is also resected. CCW 6.52. Dr. Smith sends a report to Dr. Long thanking him for the referral and includes the date the patient is scheduled for allergy testing. Various cultures have come up with their own methods to limit These cookies will be stored in your browser only with your consent. \text{Sales Revenue}&\$1,000,000&\$800,000\\ _____Coding Tip_____ Instructions for Use of the CPT Codebook When advanced practice nurses and physician assistants are working with physicians, they are . 58974 &\textbf{End of}\\ By clicking Accept All, you consent to the use of ALL the cookies. Assume temperature remains constant. Ignore air drag. Cholangiogram was negative, and patient was sent to the hospital for ERCP. A returning patient is called an established patient (EP). What modifier is used to report an evaluation and management service mandated by a court order? Make a notation in patient's medical record and in appointment book or database, Unexpected conflicts cause patients to reschedule ICD-10-CM Code Answer 1: Code in proper sequence. The balloon bursts and the payload free-falls at an altitude of 30,000 feet. An established patient returns to the physician's office for follow-up on his hypertension and diabetes. The exam is documented as expanded problem focused and the medical decision making of moderate complexity. A patient is seen by Dr. B who is covering on call services for Dr. A. CCW 6.77. It debits all acquisitions of appliances during a year to the Merchandise Inventory account. Applications are available at the American Dental Association web site, http://www.ADA.org. What is the difference between a new patient and an established patient quizlet? He spends 30 minutes in two-way communication directing the care of Mr. Trumph. CCW 6.87. A. a patient that has been seen in the office within the last 2 years. CCW 6.55. Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare and Medicaid Services (CMS). CMS DISCLAIMER. DATA REVIEW: I reviewed her lab and echocardiogram. Patient was tachypneic yesterday; lungs reveal course crackles in both bases, right worse than left. Assign the appropriate CPT code. Disclosure depends on whether, in the physicians judgment, such patients would be harmed by viewing the records. AAPC Chapter 19: Evaluation and Management, Chapter 15 Eye and Ocular Adnexa, Auditory Sy, Julie S Snyder, Linda Lilley, Shelly Collins, Exercise Physiology: Theory and Application to Fitness and Performance, Edward Howley, John Quindry, Scott Powers, Questions I Got Wrong - AD Training Center. \text{Merchandise Inventory}&\$100,000\\ NOTE: A code of 43336 should be used for the repair of the hiatal hernia (repair, paraesophageal hiatal hernia via thoracoabdominal incision). ICD-10-CM Code Answer 1: Code in proper sequence. Established patient. Upon entering the room, he finds her sitting up in bed, watching television and eating breakfast. Scheduling for Established Patients: By Telephone Out of these, the cookies that are categorized as necessary are stored on your browser as they are essential for the working of basic functionalities of the website. The infant is crying inconsolably. NOTE: A code of 44970 should be used for the laparoscopic appendectomy (laparoscopy, surgical, appendectomy). ICD-10-CM Code: Code in proper sequence. The paramedics are called to the casino he owns in Atlantic City to stabilize him and transport him to the hospital. (a) KCN/HCN\mathrm{KCN} / \mathrm{HCN}KCN/HCN, (b) Na2SO4/NaHSO4\mathrm{Na}_2 \mathrm{SO}_4 / \mathrm{NaHSO}_4Na2SO4/NaHSO4, (c) NH3/NH4NO3\mathrm{NH}_3 / \mathrm{NH}_4 \mathrm{NO}_3NH3/NH4NO3, (d) NaV/HI\mathrm NaV/HINaV/HI ? The card also details the differences in documentation requirements for level-4 visits with new and established patients. CPT is a trademark of the AMA. By CPT definition, a new patient is "one who has not received any professional services, i.e. But opting out of some of these cookies may affect your browsing experience. A patient has right trigeminal neuralgia, and gamma knife stereotactic radiosurgery was performed. California, Hawaii, Nevada, American Samoa, Guam, Northern Mariana Islands. Unfortunately, treatment was unsuccessful and . The patient has failed Claritin and Alavert and feels his symptoms continue to worsen. Upon completion of encounters, a clinician selects billing codes. Inpatient. The physician takes the blood pressure and references the patient's last three glucose tests. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL COVERED BY THIS LICENSE. The decision to repair the hernia was made, and the patient was sent to the operating room where the repair took place via the thorax and abdomen. He also performs an expanded problem history and exam and treats the patient for a URI. The oncologist spends an additional 45 minutes discussing Mr. Flintstone's new diagnosis of Hodgkin's lymphoma, treatment options and prognosis. He was hospitalized for 6 days on IV antibiotics. Other than diamond, what mineral would be best for making a sandpaper product? Also, the Merchandise Inventory account, to which the firm has debited all purchases of inventory, has a balance of $820,000 before the adjusting entry for Cost of Goods Sold, so that Goods Available for Sale totaled$820,000. A cardiologist performs a comprehensive history and comprehensive exam. The pressure of the gas is 150Pa150~\mathrm{Pa}150Pa when the height of the piston is 0.02m0.02 \mathrm{~m}0.02m. Find the force exerted by the gas on the piston. All Rights Reserved. Which elements of HPI are met in this statement? Patient safety is fundamental to delivering quality essential health services. Dr. Jones performs a problem focused exam and low medical decision making. No chest pain at present, but still SOB and some swelling in his lower extremities. someone who has not received any medical services form the provider (or any provider in the group practice) within the last 3 years, Healthcare Reimbursement/Billing Emphasis. ask 6 pt. HPI: Patient is here today for follow-up of bilateral lower extremity swelling. The physician diagnoses acquired coagulopathy due to vitamin K deficiency. Note first-time no-show on patients medical record and/or ledger card Level 4 established patient domiciliary, rest home, or custodial care visit . Case #1 Office visit (1/11/20) Dr. Smith: The patient was last seen by this primary care physician (Dr. Smith) on 12/22/18 for strep throat. The provider performs a detailed history, detailed exam and determines the patient has mild appendicitis. Services must meet specific medical necessity requirements and the level of E/M performed, based on the CMS 1995 or 1997 Documentation Guidelines for E/M Services. NOTE: A code of 63272 should be used for a laminectomy and excision procedure of an intradural lumbar lesion (laminectomy for excision of intraspinal lesion other than neoplasm, intradural; lumbar). Recheck if no improvement. ICD-10-CM Code Answer 5: Code in proper sequence. \hline Mr. Flintstone is seen by his oncologist just two days after undergoing extensive testing for a sudden onset of petechiae, night sweats, swollen glands and weakness. B. Defibrillation is performed with 250 joules to a NSR. (b) What was the speed of the payload vvv at impact? The rationale for new versus established patient is based on the provider's National Provider Identifier (NPI). Patient is taken to the operating room where a cystoscopy with ureteroscopy is performed to remove the calculus. NOTE: A code of 00944 is used for anesthesia provided to the patient for a vaginal hysterectomy procedure. CCW 6.110. All additions to the medical recorrd must be signed by. CCW 6.109. Patient presents with a history of upper abdominal pain. An established patient is one who has received professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years. We use cookies on our website to give you the most relevant experience by remembering your preferences and repeat visits. Some medical offices mail or e-mail an information packet to new patients The physician performed a TURP and transurethral resection of the bladder neck at the same time. Which E/M subcategory is appropriate to report the services provided by Dr. B? A modifier of -LT should be added to this code to indicate it was the left eye. Dr. Smith performs an expanded problem focused history and exam and discusses options with the patient on allergy management. If an entity wishes to utilize any AHA materials, please contact the AHA at 312-893-6816. Pulmonary hypertension: Etiology is not clear at this time, will work up and possibly refer to a pulmonologist. ICD-10-CM Code Answer 2. Dr. Jones performs a problem focused exam and a low medical decision making. CCW 6.52. Doctors diagnosed Lacks with cervical cancer, and as medical records show, she received the best medical treatment available to any woman for this terrible disease. Subject to the terms and conditions contained in this Agreement, you, your employees, and agents are authorized to use CDT only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. 4 What is the definition of a new patient in CPT? 52352-RT A Skyhook balloon carrying a scientific payload soars at 1000 feet per minute. Practice Quiz 7.1 (RHIA & RHIT)Practice Quiz, OST-247 - Procedure Coding - Chapters 19-21. Patient is to return to the clinic in two weeks for recheck of his breathing and follow up X-ray. A slightly different approach may be taken when Medicare patients are involved. Patient undergoes construction of apical-aortic conduit with an insertion of a single-ventricle ventricular assist device. The patient is still running above-normal glucose levels, so the physician decides to adjust the patient's insulin. This website uses cookies to improve your experience while you navigate through the website. Use of CDT is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). A patient has an EKG. A patient who has been seen by one physicians in the practice in the same specialty within the past 3 years. Give twice daily with hot packs. What term is used to describe a patient who has not been formally admitted to a health care facility __? The physician also provided E/M services that included a problem-focused history, problem-focused examination, and straightforward level of medical decision making. Unauthorized or illegal use of the computer system is prohibited and subject to criminal and civil penalties. By continuing beyond this notice, users consent to being monitored, recorded, and audited by company personnel. No additional codes are needed. Uses a basic block of time, as does wave scheduling. They often select an "Evaluation and Management" or E&M code, either for new or established patients. An established patient sees Dr. Smith, a cardiologist, at "Clinic A.". No other codes are needed. Provide parking information if needed LICENSE FOR USE OF "PHYSICIANS' CURRENT PROCEDURAL TERMINOLOGY", (CPT) CDT is a trademark of the ADA. A Leksell stereotactic head frame was placed prior to the procedure, which consisted of a single shot to a total dose of 7,500 cGy delivered to the 50 percent isodose line.