Assigning Evaluation and Management Codes - Paper

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Assigning Evaluation and Management Codes

Assigning Evaluation and Management Codes
There is an initial consultation performed for a 46-year-old woman. She has unexplained weight loss, abdominal pain, and rectal bleeding. A comprehensive history and examination is performed. The proper code ranges are 99221-99223. Although it did not state that she was admitted to the hospital, I put these codes because the words initial is in the description and a comprehensive history and examination was performed. Also the words office consultation was not used, which there are code ranges for these codes when performed in an office. The second case is a 22-year-old patient that is complaining of flu-like symptoms characterized by unremitting couth, sinus pain, and thick nasal discharge. Upon examination it was found that the patient had bronchitis and a sinus infection. The patient was prescribed a 7-day course of Zithromax. Based on the patients service appearing to be in the office and that no history being asked and only possibly the extent of the examination is documented such as the problem-focused and possibly even detailed it appears that this code range could be between 99211-99215 because it is not stating that the patient is a new patient. However, after further reviewing the information it seems as though procedure codes 99213 or 99214 would fit this service best. When comparing the table on page 165 of Valerius, Bayes, Newby, & Seggern, 2008, you can see that the each level has key components and depending on the documentation submitted it would be up to us to determine if each of these components were marked with a “Y”. I also believe that under examination possibly a detailed examination was performed because of the amount of problems this patient was having. Under medical decision making, I would say low to moderate complexity, so without seeing the full report and knowing more about this visit, I cannot just point to one procedure code....
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