The patient had been seen in the office for a level 2 E/M service on Monday morning, and a diagnosis of sinusitis was made. Her husband called at 8:00 p. m. that same evening to report his wife had become very lethargic and her speech was slightly slurred. The patient was admitted to the hospital at 8:30 p. m. by the primary care physician. The doctor performed a comprehensive history and examination, and medical decision making was of high complexity.

At 9:00 a. m. the next day, the patient was comatose and was transferred to the critical care unit. The doctor was in constant attendance from 8:10 a. m. until the patient expired at 9:35 a. m. The attending physician listed CVA (stroke) as the diagnosis.

Day of Encounter: Monday

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Day of Encounter: Tuesday

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