Question

Case 5.4 E/M

Using the most recent CPT code book available to you, find the following Evaluation and Management codes.

1. Follow-up visit, eight-year-old boy, nurse removes sutures from leg wound.
2. Office visit, twenty-nine-year-old female, established patient, follow-up on severe wrist sprain.
3. Initial office visit to evaluate gradual hearing loss, sixty-year-old female, history and physical examination, complete audiogram.
4. Initial office visit to evaluate forty-five-year-old male with complaint of shortness of breath and chest pain during exercise. Severe cardiovascular damage is suspected. Comprehensive history and examination performed; the decision making was moderately complex. Physician spent about forty-five minutes with the patient.
5. Annual physical examination of established patient, male, age forty-two.
6. Emergency department visit for a new patient with rash over entire trunk after exposure to poison ivy.
7. Initial intensive care for E/M of critically ill baby, fifteen days old.
8. Home visit for E/M of established patient with congestive heart failure (CHF); caregiver phoned report of sudden difficulty breathing and profuse sweating.
9. Medical conference of physician and psychiatrist to discuss patient’s care; approximately thirty minutes.
10. Patient, age twenty-eight, office visit for basic evaluation for life insurance.

Answer 1

E & M code:
Followup visit, eight-year-old boy, nurse removes suture from leg wound - 99211
E/Mvisit is a nurse visit or office visit should be used only medical assistance or nurse providing service like suture removal, dressing changes or wound care.

Office visit, 29-year-old female, established patient, followup on severe wrist sprain -99213
99213 is code for an office visit or put patient visit for the patient E&M code of an established patient for the assessment of the range of motion pain, contraction or sprain.

Initial office visit to evaluate gradual hearing loss, 60-year-old female, history and physical examination, complete audiogram -99203
99203 visits is an expanded problem-focused physical exam, medical decision making done by a complete history and physical examination. it is a new patient code for the initial visit.

Initial office visit to evaluate 45-year-old male with a complaint of shortness of breath and chest pain during exercise - 99205
99205 is an office or outpatient visit for E/M service. it is a new patient visit with a comprehensive history, comprehensive examination, medical decision making, and high complexity. it represents the highest level of care for a new patient.