Hcr220 Assigning Em 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

I chose this code because it is a new patient who requires a full examination and comprehensive history performed. The patient will need further testing in more than one area.

2. A 30-year-old patient presents complaining of flu-like symptoms characterized by an 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

I chose this code because it is not stated rather or not the patient is new or existing. The medical issues are of low complexity with straight forward results. A detailed examination does not need to be performed to reach a diagnosis.

3. An 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

I chose this code because it is an establish patient that does not need to see the physician. There is minimal history taken because the patient is being seen for routine blood work, not a new problem. The patient is not examined, and the decision making is minimal since the tests are normal and no change in dosage is indicated.

4. A 62-year-old diabetic female presents for check-up and a dressing change of wound on left foot. An examination reveals the wound is healing. The nurse applied a new dressing and the patient will return for a check-up in 1 week.

Code: 99214

I chose this code because it is an established patient, the examination of the wound is detailed, and moderate complexity decision making is used. The examination is focused on the wound on the left foot, and there is minimal diagnosis....