Assigning Evaluation and Management (E/M) Codes
1. Initial consultation for a 78-year-old woman with unexplained weight loss, abdominal pain, and rectal bleeding. Comprehensive history and examination performed. 99205.
This history and examination were comprehensive and dealt with several body systems, so 99205 is the better E/M code to use. 2. 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. 99202
The case does not distinguish whether the patient was a new or an established patient. Without this knowledge, I would use the code 99202. 3. 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. 99211.
This patient is an existing patient with an established history, so 99211 is the proper E/M code to use. 4. 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. 99212.
I have selected 99212 because the patient has diabetes and is there for a routine check-up and dressing change. Because the wound is healing and the patient will return for another check-up, 99212 is the best/M code.
5. A mother brings in her six-month-old male child for routine wellness check. Examination reveals the child to be in good health and making adequate progress. 99215.
This is a routine wellness check, which is an extensive visit to ensure the baby is doing well and continues developing on schedule.