Assigning Evaluation and Management (E/M) Codes
Assign appropriate E/M codes for the following five cases: o Initial consultation for a 78-year-old woman with unexplained weight loss, abdominal pain, and rectal bleeding. Comprehensive history and examination performed.
The E/M code I would use for this case would be 99205. I chose this code also since the patient is older and high complexity of the decisions the doctor may need to make. Her comprehensive examination and history will also help with determining if there are any other factors that have played into the symptoms. o 30-year-old patient presents complaining of flu-like symptoms characterized by unremitting cough, sinus pain, and thick nasal discharge. Examination reveals bronchitis and sinus infection. Patient is prescribed a five-day course of Zithromax. Although the case does not say whether it’s a new patient or existing, I am going to say the patient is an existing one. The E/M code I would use for this case would be 99213. I chose this code since examination can be expanded from ear, nose and throat to include the chest area to check the respiratory (fluid on lungs). The complexity is low since the diagnosis is limited and requires a low amount of data. o Established patient on Lithium presents for routine blood work to monitor therapeutic levels and kidney function. Nurse reviews the results and advises the patient that tests are normal and no change in dosage is indicated. The E/M code I would use for this case would be 99211. I chose this code because this is an existing patient that has an existing illness (mental) that is being managed. The doctor just wants to make sure the kidney is still functioning properly by taking routine blood work. All contact for this visit is minimal.
o 62-year-old diabetic female presents for check-up and dressing change of wound on left foot. Examination reveals that the wound is healing. Nurse applied new dressing and patient will return for check-up in one week. The E/M code I would use for
The E/M code I would use for this case would be 99205. I chose this code also since the patient is older and high complexity of the decisions the doctor may need to make. Her comprehensive examination and history will also help with determining if there are any other factors that have played into the symptoms. o 30-year-old patient presents complaining of flu-like symptoms characterized by unremitting cough, sinus pain, and thick nasal discharge. Examination reveals bronchitis and sinus infection. Patient is prescribed a five-day course of Zithromax. Although the case does not say whether it’s a new patient or existing, I am going to say the patient is an existing one. The E/M code I would use for this case would be 99213. I chose this code since examination can be expanded from ear, nose and throat to include the chest area to check the respiratory (fluid on lungs). The complexity is low since the diagnosis is limited and requires a low amount of data. o Established patient on Lithium presents for routine blood work to monitor therapeutic levels and kidney function. Nurse reviews the results and advises the patient that tests are normal and no change in dosage is indicated. The E/M code I would use for this case would be 99211. I chose this code because this is an existing patient that has an existing illness (mental) that is being managed. The doctor just wants to make sure the kidney is still functioning properly by taking routine blood work. All contact for this visit is minimal.
o 62-year-old diabetic female presents for check-up and dressing change of wound on left foot. Examination reveals that the wound is healing. Nurse applied new dressing and patient will return for check-up in one week. The E/M code I would use for