Evaluation and Management Coding Practice:
S: Monica Sullivan was seen in the office by Dr. White on 12/13 for the second time. She presented with a chief complaint of dizziness and weakness; she stated that she wanted to have her blood pressure checked.
O: Patient has been on Vasotec 5 mg and Hydrodiuril 25 mg. BP has been going up at home. Patient has felt ill, weak, and dizzy, with headache for three days. Cardiovascular exam was normal. BP of 130/110 and pulse rate of 84. Her temperature is 98.6°F and normal.
A: Accelerated hypertension. Bell's palsy.
P: Increase Vasotec to 5 mg a.m. and 2.5 mg p.m. SMA & CBC.
E/M category/subcategory: Office or Other Outpatient Services, Established Patient
Determine the extent of history obtained:
Determine the extent of examination performed:
Determine the complexity of medical decision making:
CPT E/M code:
To determine the extent of history obtained in this case, we can use the four components of history: chief complaint (CC), history of present illness (HPI), review of systems (ROS), and past medical, family, and social history (PFSH).
In this case, the chief complaint is stated as dizziness and weakness, and the patient also stated that she wanted to have her blood pressure checked. This information is considered part of the chief complaint (CC).
The history of present illness (HPI) includes the patient's symptoms of feeling ill, weak, and dizzy for three days, along with a headache. This information contributes to the extent of history obtained.
The review of systems (ROS) is not explicitly mentioned in the given information. We don't have any information about the patient's review of systems.
The past medical, family, and social history (PFSH) is also not mentioned in the given information. We don't have any details about the patient's past medical history, family history, or social history.
Based on the given information, we have obtained the CC and some HPI. However, since we don't have any documented ROS or PFSH, we can classify the extent of history obtained as "problem focused."
Next, let's determine the extent of examination performed.
The cardiovascular exam is mentioned in the given information, and it is stated to be normal. No other specific examination components are mentioned.
Based on the information provided, we can classify the extent of examination performed as "expanded problem focused." This includes a limited examination of the affected body area or organ system (in this case, the cardiovascular system).
Finally, let's determine the complexity of medical decision making.
To assess the complexity of medical decision making, we consider three elements: the number of diagnoses or management options, the amount and/or complexity of data to be reviewed, and the risk of complications or morbidity/mortality.
In this case, the provider identified two diagnoses - accelerated hypertension and Bell's palsy. This contributes to a moderate level of complexity.
Regarding data review, the provider may need to review the patient's medical history, current medications, vital signs, and any previous test results. The given information doesn't directly mention the amount or complexity of data reviewed, so it is unclear.
Regarding the risk of complications or morbidity/mortality, the given information describes an elevated blood pressure (130/110) but does not provide any additional information on the patient's overall risk. Without further details, it is difficult to assess the risk level.
Based on the information provided, we can classify the complexity of medical decision making as "moderate."
Now, let's determine the CPT E/M code.
Based on the extent of history obtained (problem focused), extent of examination performed (expanded problem focused), and complexity of medical decision making (moderate), the appropriate CPT code for this encounter would be CPT code 99213.
Please note that the final CPT code selection should be done in accordance with the official coding guidelines and the specific requirements of the payer or billing entity.