Question

Review the case below and answer the questions to assign the E/M office or other outpatient code. (You will have to identify the elements documented in the case to determine the level of history, level of examination, and complexity of medical decision making.)

SUBJECTIVE: A 54-year-old female patient is seen in the office for routine three-month follow-up for evaluation and management of type 2 diabetes mellitus and hypertension. The patient has no new complaints today; she denies chest pain, headache, numbness of the extremities, shortness of breath, or visual changes. The patient states that she has remained on the diet recommended during the last E/M visit and that she is regularly exercising. Home monitoring of blood pressure and glucose levels are within normal limits.

OBJECTIVE: Blood pressure 130/78. Weight 145. Pulse 78, regular. HEAD, EYES, EARS, NOSE, THROAT: Pupils equal, round, and reactive to light and accommodation. External auditory canals and tympanic membranes negative. Oropharynx benign. NECK: Supple. No bruits, jugular venous distention, or thyromegaly. CHEST: Breath sounds clear to auscultation and percussion. No rubs, rales, rhonchi, or wheezing. HEART: No click, gallop, irregularity, murmur, or rub. EXTREMITIES: Distal pulses intact. No cyanosis, clubbing, or edema. NEUROLOGICAL: Deep tendon reflexes within normal limits and symmetrical. No decreased lower extremity sensation noted. LAB RESULTS: Fasting blood sugar 132. Urinalysis within normal limits.

ASSESSMENT: Type 2 diabetes mellitus, controlled. Benign hypertension.

PLAN: Glucotrol 5 milligrams daily, every morning. Procardia XL 30 milligrams daily. Relafen 1,000 milligrams daily. Continue home glucose monitoring. SMA-7 and glycosylated hemoglobin today. Return for routine follow-up in three months.a.

1. Is this patient new or established?
2. What is the extent of history?

Answer 1

a, This is established patient
The established patient receives service now from the same physician or covering physician in the same specialty or associated office or clinic or subspeciality within the past three years,
New patients may not receive any medical service from the speciality from the same physician within the past three years. they will come to speciality for their first encounter.
b, Established patients can be seen by covering physician anywhere in the office and clinics for their routine care. E/M service key components are history, examination and medical decision making.
Patient history has no present history of illness. so the patient presenting problem is less. typically takes only 5 minutes for performing this service. CPT code 99211 is for established patient office visits.