* Initial consultation is performed for a 78-year old woman with unexpected weight loss, abdominal pain, and rectal bleeding. A comprehensive history and examination is performed. The components were comprehensive and the decision was high complexity the code is 99205 * A 30-year old 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.
The component was the expanded problem- focused and the decision was straightforward the code is 99202 * 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; a no change in dosage is indicated. The component and the decision was minimal the code is 99211 * A 62- year old 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. The components were detailed and the decision was moderate complexity the code is 99214 * 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 CLAIMS PREPARATION I: CLEAN BILLS OF HEALTH 2 components were problem focused and the decision was straightforward the code is 99212.