DB 2
docx
keyboard_arrow_up
School
Herzing University *
*We aren’t endorsed by this school
Course
611
Subject
Medicine
Date
Feb 20, 2024
Type
docx
Pages
2
Uploaded by KDaniels2024
Use your lecture materials to determine what CPT E&M Code to utilize for this ‘new patient’ encounter.
You may choose to assign the code based on the anticipated/guestimate amount of time the provider would spend with the patient in the encounter or you may choose to utilize the Medical Decision Making (MDM) approach. If
you choose the MDM include the following information in your discussion:
1.
the level of history taking achieved – identify the history elements present
2.
the type of exam performed – identify the number of systems and bulleted points in the note
3.
the level of medical complexity encompassed – include # of points for a) diagnoses/management options, b) amount/complexity of data reviewed and c) level of risk for complications, morbidity, mortality
The purpose of CPT E&M codes is to bill or reimburse healthcare facilities for services rendered. In the scenario given, the patient is new, with what seems to be a chronic issue since it has been
going on for 2 months. Since this patient is new, a detailed assessment needs to be completed and address his current issue or chief complaint. I would code this patient base on patient status
and time spent in the patient encounter. Regardless of whether counseling and/or care coordination predominate the treatment, time may be used to choose a code level in the office or other outpatient settings (AMA, 2021). Only when counseling and/or care coordination takes center stage in the service can time be utilized to determine the amount of other E/M services (AMA, 2021). The CPT E/M code I would use for this patient is 99204. Since the visit included obtaining a health history, performing a medically necessary examination, ordering the ketoconazole, documenting clinical information, and providing patient education, these tasks all fall under what needs to be calculated based on time. Medical Decision Making (MDM) is based on the complexity of the visit. Because the patient’s encounter is not complex and I would not have data to support it, I would not use MDM for coding. The history of elements present in this scenario is a new problem (the rash) and an additional workup is required because the patient is new, that would be 4 points in the number of diagnoses and management options of MDM. Secondly, the amount and or complexity of data reviewed in this scenario is 1 because the medication was ordered. Lastly, the risk of complications, morbidity, or mortality would be minimal because the patient has only one or a minor problem. Because this visit did not score 2 or more points within the categories, it is not considered a high-complexity visit. This visit would be considered straightforward. Reference
American Medical Associates. (2021). Code and guideline changes | AMA
. https://www.ama-
assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
- Access to all documents
- Unlimited textbook solutions
- 24/7 expert homework help