Chapter 5
Chapter Five Reading Assignment
Evaluation and Management (E/M) services describe face-to-face visits which are rendered by clinical providers. These visits are reported either by time spent with the patient or by the level of evaluation performed on a patient and the site of service in which the evaluation took place. The physician performs and reports E/M codes and it is his documentation that must support the level of service for which he bills. Only the provider is aware of what he actually does when performing an evaluation of a patient and only the provider is able to appropriately transfer the “language” of the evaluation he performs (dictation) into its numeric coding equivalent. The coder is, however, responsible to make sure that the provider’s definition of what he has performed is accurate, that his documentation indeed meets the level of service reported, and, if other services were performed in addition to the E/M on the same date of service, that the appropriate modifiers are utilized for all services provided including the E/M service.
Reference Material
Chapter Five Homework
Code the following E/M services as well as all pertinent diagnoses.
1. Select an appropriate E/M code for an initial office visit of a 32-year-old male complaining of shortness of breath. The physician took a brief history of the presenting problem, and performed a limited exam of the chest, respiratory system, ears, nose and throat, and cardiovascular system. His assessment indicated moderate risk of complications and moderate management options were necessary. He ordered a chest x-ray after performing an EKG in his office, which showed no abnormality.
2. A 25-year-old established patient presents to the physician’s office complaining of pain in his knee. He states that he has been exercising regularly and only began having the pain recently. The physician records the patient’s vital signs (BP, temp, and weight) and examines the patient’s lungs and heart, which are normal. Upon examining the patient’s knee, the physician determines that the patient has bursitis for which he provides a joint injection for the pain.
3. A 45-year-old female presents to the ER with a fever and CHF. The ER physician performs a detailed history, a comprehensive exam and medical decision making of high complexity. He decides upon completion of the exam to admit the patient to the hospital. She has a history of rheumatic fever as a child.
4. A 65-year-old female presents to the hospital where she is admitted to the critical care unit for acute respiratory failure from asthma. The attending physician spends 80 minutes caring for the patient and reviewing test results and chart notes monitoring her care. The patient is stabilized and the physician returns to his office to see his scheduled patients.
5. Dr Smith visits the nursing home and does an initial nursing facility assessment (MDS/RAI and medical plan of treatment) of a 72-year-old insulin dependent diabetic amputee with hearing and visual impairments and possible dementia seen in the office the day before and judged to require nursing facility care.
6. A 27-year-old patient is admitted to OB unit attempting VBAC. Fetal monitoring shows increasing fetal distress. Patient’s blood pressure is rising and labor progressing slowly. A neonatologist is requested by the OB/GYN to standby in the unit for a possible cesarean delivery and neonatal resuscitation.
7. The physician sees a patient after completion of treatment for a release to return to work following an injury. The employer requires a form identifying history, exam, assessment of capabilities, patient stability, and possible future medical treatment.
8. A newborn is assessed and discharged from the hospital on the same date of service. What code would be used?
9. The medical record indicates that the physician overseeing a patient’s care at a skilled nursing facility discussed the care plan and made appropriate modifications during the month. The documentation is as follows:
2nd 12 minutes – change patient diet due to high cholesterol
8th 23 minutes – patient fell during physicial therapy, bruising hip
22nd 19 minutes – change of medication due to bradycardia
26th 9 minutes – allow patient pass to visit with family for the weekend
31st 13 minutes – low back pain check
10. What series of codes are utilized to report services provided to a patient admitted to the ER on 6/13/14 who is observed to make sure there is no change in their condition after receiving a shot for migraine headaches. The patient is observed for 15 hours and on 6/14/14 is sent home.