Physical Examination and Assign Appropriate E/m

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Assignment: Assigning Evaluation and Management (E/M) Codes



By: Jeanette Ritchie

Assign appropriate E/M codes for the following five cases:    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. Per 2010 CPT, Medicare doesn't recognize Consultation codes. Since the patient is 78, are we to make the leap that we are billing Medicare? more than likely. So the 99205 would be correct. The nature of her presenting problem (unexplained weight loss, abdominal pain, and rectal bleeding) is high MDM. Multiple DX, tests, and high risk are present. Remember we only need 2 out of 3 for MDM.   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. This is an office visit, new patient but the history and PE is expanded problem focused because the patient have 2 or more conditions but the treatment is straight forward that is why we have to use 99202. ·    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. 99211 - This is clearly an incident-to service. The nurse is following the guidelines set forth by the physician.      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. 99214..nature of presenting problem..the...
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