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. New patient, comprehensive Code 99204. I chose this code because the patient is a new patient and because the problems listed seem to call for general examination of multiple systems or a complete examination of a single organ system.
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.
Since there is no information stating whether this patient is a new or established patient, I will assume he/she is a new patient. I choose code 99203. The information met two of the three components. They are medical decision making of low complexity and a detailed examination.
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. Since this is an established patient and the information meets at least two of the three components, I chose code 99213. The two components I feel were met are; expanded problem focused history and medical decision making of 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 code 99212, the patient is obviously an established patient because it states she is there for a check-up and all information seems to be problem focused with straightforward decision making.
A mother brings in her 6-month-old male child for a routine wellness check....
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