Assigning E/M Codes

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Assigning E/M codes
4-14-2013

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.

* I chose E/M code 99205 for this situation because the patient is obviously a new patient who is in need of a full examination for multiple issues or problems. The patient will need extensive testing in more areas then one.

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.

* I chose E/M code 99202 because it does not state whether or not the patient is a new existing patient or an established patient. The medical issues for the patient are of low complexity with straight forward results and a detailed examination will need to be performed in order to diagnose the patient.

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.

* I chose E/M code 99211 because the patient is stated to be an established patient. The two components that were met to help me make this decision would be the fact that the patient has been going through this issue for a while which would make this an expanded problem-focused. So the medical decision would have been easier to make which would make it low-complexity.

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 for a check-up in one week.

* I chose E/M code 99212 because the patient is an existing patient and she is only coming for a check-up and a dressing change. This would make...
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