Patient is admitted to the hospital with acute abdominal pain. The attending medical physician requests a surgical consult. The consultant agrees to see the patient and conducts a comprehensive history and physical examination. The physician ordered lab work to rule out pancreatitis, along with an ultrasound of the gallbladder and abdominal x-ray. Due to the various diagnosis possibilities and the tests reviewed, a moderate medical decision was made.

Question

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The comprehensive history, physical examination, ordered lab work, ultrasound and x-ray all suggest that the consultant made a moderate medical decision in determining the best course of treatment for the patient. This level of decision-making is consistent with the requirements for a level 4 consultation according to the documentation guidelines. Therefore, the best choice is C) 99254.

Patient Is Admitted to the Hospital with Acute Abdominal Pain