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HCR/220 October 30, 2011 Assignment: Assigning Evaluation and Management (E/M) Codes #1. 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. Code: 99205 Seeing as though this patient is 78 years old, we are assuming that we are billing Medicare for these procedures. I chose the code above due to the presentation of problems such as unexplained weight loss, abdominal pain and rectal bleeding because it is a high MDM and that this patient is considered high risk. #2.
A 30-year-old returning 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. Code: 99202 This is an office visit, new patient but the history of the same symptoms as prior office visit. The patient still has 2 or more conditions but the treatment is straight forward that is why we have to use 99202. #3. 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. Code: 99211 This is an example of incident to service. The nurse is following the guidelines set forth by the physician. #4. A 62-year-old established 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. Code: 99212 I chose this code due to it being problem-focused but yet straightforward.
Due to the patient having diabetes the risk was minimal and important for her wounds to heal on the feet of diabetic patients. If wounds are not treated, she can lose her foot. #5. A mother brings in her 6-month-old male child for a routine wellness check. An examination reveals the child to be in good health and making adequate progress. Code: 99215 The child of 6 months old has probably been seen before because of prior medical history. The visit was of high complexity and comprehensive. This is why I chose the code 99215.