An office consultation is performed for a post-menopausal woman who is complaining of spotting in the past 6 months with right lower quadrant tenderness. A detailed history and physical were performed with a low-complexity medical decision.

Question

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A detailed history and physical exam were performed, which meets the requirements for a level 3 (99243) office consultation. The presence of right lower quadrant tenderness warrants additional workup, which increases the complexity of the medical decision-making.

An Office Consultation Is Performed for a Post-Menopausal Woman Who