Assigning EM Codes

Topics: Physical examination, Inspection, Medical record Pages: 2 (443 words) Published: February 26, 2014


Assigning E/M Codes
HCR220
February 16, 2014
UOPX
Assigning E/M Codes
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. This is an office visit for a new patient with a comprehensive history and physical exam. The code range for new patients is 99201 to 99205. There is a consultation code which range from 99241 to 99255. But in 2010 Medicare announced that they would stop paying for consult codes. This code has to be documented in the patient’s records though. (McGraw-Hill, 2012) The correct code for comprehensive history and physical examination with high decision making would be 99205.

A 30-year-old patient presents complaining of flu-like symptoms characterized by an 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 E/M code for the 30-year-old patient is 99202 because it does not state whether or not the patient is a new 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. 

An 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.

The codes for established patient range from 99211 to 99215. This patient is stated to be an established patient. Since the patient had a routine blood test and only saw the nurse the correct E/M code would be 99211.

A 62-year-old diabetic female presents for check-up and a dressing change of wound on left foot. An examination reveals the wound is healing. The nurse applied a new dressing and the patient will return...

Cited: McGraw-Hill. (2012). Medical Insurance. In Claim Coding (p. 162). The McGraw-Hill Corporation.
McGraw-Hill. (2012). Medical Insurance. In Claim Coding (p. 167). The McGraw-Hill Corporation.
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