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…
new patient.
o A 35-year-old comes in for suture removal from a simple laceration on his arm. The nurse notifies the physician, who instructs the nurse to remove the sutures.
After removal, the nurse evaluates the site and documents an absence of infection and erythema. Wound care instructions are provided by the nurse.
This would be a problem focused for an established patient since the patient has been in before to have the surgery and has come back to get their stitches removed from what I have gathered. The E/M code that would go along with this would be 99212 because it is also straight forward procedure that did not require any checkups to find a problem.
o A 26-year-old female presents to the office complaining of ongoing abdominal pain for the past 4 days. She describes the pain as cramping, associated with diarrhea and states that it has progressively worsened over the last 24 hours. Patient does not have an appetite, is pale and appears very lethargic. She also has a slight fever. She hasn’t experienced frequent or painful urination, but she has noticed bright red blood in her stool. Social, family and previous medical history were taken. Other examinations performed include: cardiovascular, respiratory, heart, lungs, gynecological, abdominal, and HEENT (head, eyes, ears, nose, and throat).
This sounds as if she is a new patient to this office and is in serious examination.
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
performed.
It states this is an initial consultation which means this is a new patient coming in for problems and is in need of assistance. It states the exam and history are comprehensive and has been performed. The E/M code I believe I would use is the 99204 for comprehensive with moderate complexity. Also since there are few different multi system signs at hand there would be a comprehensive tests ran on multi systems that might cause the problems with the affected areas.
Reference List:
HCR 220 Chapters 5 Pages 161-165 Table 5.4
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…
new patient.
o A 35-year-old comes in for suture removal from a simple laceration on his arm. The nurse notifies the physician, who instructs the nurse to remove the sutures.
After removal, the nurse evaluates the site and documents an absence of infection and erythema. Wound care instructions are provided by the nurse.
This would be a problem focused for an established patient since the patient has been in before to have the surgery and has come back to get their stitches removed from what I have gathered. The E/M code that would go along with this would be 99212 because it is also straight forward procedure that did not require any checkups to find a problem.
o A 26-year-old female presents to the office complaining of ongoing abdominal pain for the past 4 days. She describes the pain as cramping, associated with diarrhea and states that it has progressively worsened over the last 24 hours. Patient does not have an appetite, is pale and appears very lethargic. She also has a slight fever. She hasn’t experienced frequent or painful urination, but she has noticed bright red blood in her stool. Social, family and previous medical history were taken. Other examinations performed include: cardiovascular, respiratory, heart, lungs, gynecological, abdominal, and HEENT (head, eyes, ears, nose, and throat).
This sounds as if she is a new patient to this office and is in serious examination.
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
performed.
It states this is an initial consultation which means this is a new patient coming in for problems and is in need of assistance. It states the exam and history are comprehensive and has been performed. The E/M code I believe I would use is the 99204 for comprehensive with moderate complexity. Also since there are few different multi system signs at hand there would be a comprehensive tests ran on multi systems that might cause the problems with the affected areas.
Reference List:
HCR 220 Chapters 5 Pages 161-165 Table 5.4