E/M Nursing Codes: A Case Study
Assigning Evaluation and Management (E/M) Codes
o A 7-year-old is brought into the office unexpectedly by his mother on a very busy clinic day. He is coughing and wheezing. He has no known history of asthma, but frequently gets like this while playing soccer. He is in moderate distress. An H&P and physical exam is performed.
As there is no previous history of asthma within the patient the issue is an extended problem focused with E/M Code 99202 due to the fact the mother reports it happening every time he plays soccer so could be sports induced asthma but will need extended tests of the area and related areas to the issue at hand. Also this code represents new patients. Since there is nothing stated that he was a current patient at this clinic I am treating as a …show more content…
Since such a thorough examination has taken place to find the extent of the problem the E/M code I would assign would be 99205 due to being comprehensive due to the wide range of tests and several key components are being done such as checking the detailed history of the patient and doing such a detailed examination of the patient.
o A 42-year old diabetic female presents with nasal stuffiness, a sinus headache, a sore throat and an unrelenting cough. You spend 12 minutes reviewing problems, diagnosing the patient as having sinusitis, and discussing treatment options. The patient is prescribed a 7-day course of the antibiotic Levaquin.
Since the patient is a diabetic she is more than likely a current patient that goes to the clinic on a regular basis. It is a straight forward examination that does not take much time, effort, or even tests in order to tell what is wrong and looks to be problem focused so the E/M code I would assign would be 99212
o Initial consultation for a 78-year-old woman with unexplained weight loss, abdominal pain, and rectal bleeding. Comprehensive history and examination
o A 7-year-old is brought into the office unexpectedly by his mother on a very busy clinic day. He is coughing and wheezing. He has no known history of asthma, but frequently gets like this while playing soccer. He is in moderate distress. An H&P and physical exam is performed.
As there is no previous history of asthma within the patient the issue is an extended problem focused with E/M Code 99202 due to the fact the mother reports it happening every time he plays soccer so could be sports induced asthma but will need extended tests of the area and related areas to the issue at hand. Also this code represents new patients. Since there is nothing stated that he was a current patient at this clinic I am treating as a …show more content…
Since such a thorough examination has taken place to find the extent of the problem the E/M code I would assign would be 99205 due to being comprehensive due to the wide range of tests and several key components are being done such as checking the detailed history of the patient and doing such a detailed examination of the patient.
o A 42-year old diabetic female presents with nasal stuffiness, a sinus headache, a sore throat and an unrelenting cough. You spend 12 minutes reviewing problems, diagnosing the patient as having sinusitis, and discussing treatment options. The patient is prescribed a 7-day course of the antibiotic Levaquin.
Since the patient is a diabetic she is more than likely a current patient that goes to the clinic on a regular basis. It is a straight forward examination that does not take much time, effort, or even tests in order to tell what is wrong and looks to be problem focused so the E/M code I would assign would be 99212
o Initial consultation for a 78-year-old woman with unexplained weight loss, abdominal pain, and rectal bleeding. Comprehensive history and examination