Question

Before coding the evaluation and management records, review the following definitions.

CPT E/M Coding

As you have previously learned, there are five steps to the assignment E/M CPT codes:

• Step 1: Determine the main term by determining the type of service, place of service, and patient status.
• Step 2: Determine the level of history.
• Step 3: Determine the level of examination.
• Step 4: Determine the complexity of medical decision making.
• Step 5: Determine final code assignment

History
HPI: 16 Mos male with fever x3d. Patient was in his usual state of health until this past Saturday, when he developed tactile fevers. This morning, he was fussy and spiked a high fever (Tm 104), which prompted this ED visit. He has been taking ibuprofen and tylenol with transient relief in fevers. Other associated symptoms include NBNB emesis x2, rhinorrhea, decreased PO, and loose stools. He has been urinating normally. There are no sick contacts at home.
Seen by PMD on January 10th with blister on throat, completed 10 days of amoxicillin.
Past Medical History:
Thalassemia (baseline Hgb ~10)
Past Surgical History: No past surgical history on file.
Allergies: No Known Allergies
Immunizations: Immunizations Up to Date: Yes
Medications: The patient's current medications are listed in the medication portion of the chart.
Family History:
Thalassemia trait
Hepatitis (mom)
Social History:
Daycare or School: no
Smokers: yes
Review of Systems:
As per HPI, all other review of systems is negative
PHYSICAL EXAM:
Pulse:
130
Temp:
36.8 °C (98.2 °F)
Resp:
24
Weight:
11.4 kg
General: Awake, alert, interactive
HEENT: Normocephalic, atraumatic, PERRL, EOMI, anicteric, MMM, OP clear, TM erythema BL
Lungs: Good aeration and respiratory effort, CTA without wheezing or focality
Heart: RRR, S1/S2 present, no murmur/rub/gallop, strong pulses bilaterally
Abdomen: Soft, non-distended, non-tender, normoactive bowel sounds, no HSM
Evaluation and Management Case 009
Skin: Good turgor, faint maculopapular rash on lower ext, no petechiae/ecchymoses appreciated
Neuro: Alert, interactive, normal strength and tone
Assessment/Plan: 16 month old with likely viral illness. TM erythema suggestive of an evolving AOM. He is well appearing and well hydrated on exam. Given history of fever, will treat for AOM.
- Amox x10 days
- Supportive care
Resident/APN:

Answer 1

E/M stands for “evaluation and management”. E/M coding is the process by which physician-patient encounters are translated into five-digit CPT codes to facilitate billing. CPT stands for “current procedural terminology.” These are the numeric codes which are submitted to insurers for payment.

Here in the present scenario, we can observe that the 16-year-old male has got admitted in the emergency department and undergone a thorough history taking includes present history, past history and family history, and as well as he has undergone a thorough physical examination and review of systems was found negative and is a plan that he is likely to have viral illness and Acute otitis media

Here the patient has undergone an  :

• Expanded problem-focused history
• Expanded problem-focused examination
• Medical decision making of low complexity
• Presenting problem(s): Low or moderate severity

Thus here we can apply the E/M CPT code as 99282