April 16 2012
Assigning Evaluation and Management (E/M codes)
1. Initial consultation is performed for a 78-year-old woman with unexplained weight loss, abdominal pain, and rectal bleeding. A comprehensive history and examination is performed. The code that I will be using is the 99204. The patient is 78 years old, so I am assuming that we will be billing Medicare for the procedures. The reason why I choose the code 99205 is because of the symptoms she is having. The unexplained weight loss, abdominal pain, and rectal bleeding is high in MDM and considering she is old and so, she is considered high risk.
2. A 30-year-old patient presents complaining of flu-like symptoms characterized by unremitting cough, sinus pain, and thick nasal discharge. An examination reveals bronchitis and sinus infection. The patient is prescribed a 5-day course of Zithromax.
The code that I will be using is 99202. The reason why I choose this code is because the person is young and he had examination done and it was a low to moderate severity and he was given a straightforward medical decision making. He was given also an anti-biotic to cure his complaint.
3. Established patient on Lithium presents for routine blood work to monitor therapeutic levels and kidney function. A nurse reviews the results and advises the patient that tests are normal, and no change in dosage is indicated. In this example, I will choose to use the code 99211 because the key components are not require, the physician does not need to be present as long as it is under the supervision of the nurses. This is an example of incident to service. The nurse is following the guidelines to report to the physician.
4. A 62-year-old diabetic female presents for check-up and dressing change of wound on left foot. An examination reveals the wound is healing. The nurse applied new dressing and patient will return...