Individual Assigning Analysis and Managing (E/M) Rules 1 . First consultation for a 78-year-old woman with unexplained weight loss, abdominal pain, and rectal bleeding. Comprehensive background examination performed. 99205 This history and evaluation were thorough and addressed several body system systems, so 99205 may be the better E/M code to use. 2 . 30-year-old patient shows complaining of flu-like symptoms characterized by unremitting cough, sinusitis pain, and thick nose discharge. Assessment reveals bronchitis and sinusitis infection.
Patient is recommended a five-day course of Zithromax. 99202 The truth does not separate whether the patient was a fresh or an established patient. Devoid of this understanding, I would make use of the code 99202.
3. Founded patient in Lithium shows for regimen blood job to monitor therapeutic amounts and renal function. Nurse reviews the results and advises the sufferer that assessments are usual and no enhancements made on dosage can be indicated. 99211 This affected person is a preexisting patient with an established record, so 99211 is the right E/M code to use. 4. 62-year-old diabetic female presents for check up and dress up change of wound on left foot.
Examination reveals that the wound is curing. Nurse used new dressing and affected person will return for check up in one week. 99212 I use selected 99212 because the affected person has diabetes and is presently there for a schedule check-up and dressing change. Because the injury is treatment and the sufferer will return for another check-up, 99212 is the best/M code.
5. A mother earns her six-month-old male child for regimen wellness examine. Examination shows the child being in good health and making adequate progress. 99215 This is certainly a routine wellness verify, which is an extensive visit to guarantee the baby is doing well and continues producing on schedule.