Evaluation and Management Coding Practice: Ginny Tallman is a 73-year-old female who is followed in the Medical Clinic for COPD. Her medications include Theo-Dur 300 mg by mouth daily in the morning. History of present illness reveals that she seems to have adequate control of her bronchospasm using this medication. She also uses an albuterol inhaler two puffs p.o. q6h. She has no recent complaints of acute shortness of breath and no chest tightness. She has a chronic, dry cough, productive of scanty sputum. At this time, she is complaining of shortness of breath.
PE reveals an elderly female in no real distress. BP in the left arm, sitting, is 110/84, pulse 74 per minute and regular, respiratory rate 12 per minute and somewhat labored. Lungs reveal scattered wheezes in both lung fields. There is also noted an increased expiratory phase. Cardiovascular exam reveals no S3, S4, or murmurs.
The impression is COPD with asthmatic bronchitis. The patient will have present medications increased to Theo-Dur 300 mg by mouth daily in the morning and 400 mg by mouth each evening. She should receive follow-up care in the clinic in approximately two months' time.
E/M category/subcategory: Office or Other Outpatient Services, Established Patient
Determine the extent of history obtained:
problem focused
Determine the extent of examination performed:
Determine the complexity of medical decision making:
CPT E/M code:
Based on the provided information:
Extent of history obtained: Problem focused
Extent of examination performed: Limited
Complexity of medical decision making: Moderate
CPT E/M code: 99213
To determine the extent of examination performed and the complexity of medical decision making, we will need to refer to the Evaluation and Management (E/M) guidelines for office or other outpatient services, established patient.
1. Extent of Examination:
In the given scenario, the physical examination (PE) findings are described, including the patient's blood pressure, pulse, respiratory rate, and lung and cardiovascular exams. To determine the extent of examination, we can match the provided documentation with the levels of examination described in the guidelines:
- Problem Focused: Limited examination of the affected body area or organ system (1-5 bullets).
- Expanded Problem Focused: Limited examination of the affected body area or organ system and other symptomatic or related organ system(s) (6-11 bullets).
- Detailed: Extended examination of the affected body area(s) or organ system(s) and other symptomatic or related organ system(s) (12 or more bullets).
- Comprehensive: General multi-system examination or complete examination of a single organ system (bullets exceeding the minimum for detailed).
Based on the information provided, the documentation includes examination findings related to the lungs and cardiovascular system. It does not mention other symptomatic or related organ systems. Therefore, the extent of examination performed in this case would be considered "problem focused."
2. Complexity of Medical Decision Making:
Medical decision making involves assessing the complexity of the patient's condition and the level of management required. This is based on three elements: the number of diagnoses or management options, the amount and/or complexity of data to be reviewed, and the risk of complications.
In the given scenario, the clinician mentions the patient's current medications and the plan to increase one of them. This suggests limited management options and relatively straightforward decision making. However, the documentation does not provide detailed information on the amount or complexity of data reviewed, or the risk of complications.
Given the limited information provided, it is difficult to accurately determine the complexity of medical decision making. However, based on the simplicity of the presented case, it could be classified as "straightforward" or "low complexity."
3. CPT E/M Code:
To assign the appropriate E/M code, we need to consider the levels of history, examination, and medical decision making. Based on the extents determined:
- History: Problem Focused
- Examination: Problem Focused
- Medical Decision Making: Straightforward or Low Complexity
The E/M code for an established patient office or other outpatient service with problem-focused history, problem-focused examination, and straightforward or low complexity medical decision making would typically be CPT code 99212.
Please note that the final selection of the E/M code should be made based on the comprehensive review of all relevant documentation to ensure accuracy. The provided information is a general guide and should not be considered as the sole basis for coding.