This is an established patent seen in the office by his regular physician due to increasing respiratory distress for the 12 hours, unrelieved by his usual routine of Capoten. The patient has a long standing history of severe bronchial asthma, hiatal hernia with reflux and hypertension. no history of N. V. or other symptoms. What E/M code should I use?

Question

This is an established patent seen in the office by his regular physician due to increasing respiratory distress for the 12 hours, unrelieved by his usual routine of Capoten. The patient has a long standing history of severe bronchial asthma, hiatal hernia with reflux and hypertension. no history of N. V. or other symptoms. What E/M code should I use?

Answer 1

To determine the appropriate E/M code for this patient's visit, you need to consider both the level of service and the type of service provided. E/M codes are used to classify physician-patient encounters based on the complexity and intensity of the service provided. There are several key components that need to be assessed to determine the appropriate code:

1. History: Here, the patient's history includes factors such as a long-standing history of severe bronchial asthma, hiatal hernia with reflux, and hypertension. The patient is experiencing increasing respiratory distress for the past 12 hours. No information is provided regarding the patient's previous treatment or medications.

2. Examination: The question does not provide any information about the physical examination performed by the physician.

3. Medical Decision Making (MDM): MDM involves assessing the complexity of the patient's condition, the number of diagnoses, the amount of data reviewed, and the risk associated with the management options. The information provided mentions the patient's increasing respiratory distress unrelieved by their usual routine of Capoten. However, no information is provided regarding other management options considered by the physician or the potential risk involved.

Based on the limited information provided, it is not possible to definitively determine the appropriate E/M code. However, it is worth noting that the history component seems to indicate a complex medical condition, and the presence of increasing respiratory distress raises the level of concern. It would be advisable to consult the documentation guidelines provided by the relevant coding system (such as the Current Procedural Terminology or CPT® manual) and thoroughly review the complete medical record to make an accurate determination of the appropriate E/M code. It is important to consider all relevant factors to ensure accurate coding and billing.