Question

E/M code needed. A 35-year-old female was admitted to the substance abuse treatment center for management...

E/M code needed.

A 35-year-old female was admitted to the substance abuse treatment
center for management of her drug addiction. Her addictive medicine
physician had asked a gynecologist to evaluate her complaints of severe
pelvic pain, The gynecologist could hot identify any specific pathology
that might be causing the problem. The patient continued to complain
of worsening pelvic and rectal pain, and a second consultation was
sought. The second gynecologist performed a complete head-to-toe
physical examination and talked to the patient at great lengths to gather
her medical history of present illness, including her complete past
medical, family and social history The second gynecolgist
recommended an immediate laparoscopic examination to rule out
multiple conditions such as endometriosis and other uterine and
ovarian pathology. The physician indicates the patient is in a high-risk
category. Code the second gynecologist services.

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Answer #1

Code the second gynecologist services.

HISTORY

99223 patient admitted due to problems of high severity

PHYSICAL EXAMINATION

Z00.00 - Encounter for general adult medical examination without abnormal finding

MEDICAL DECISION MAKING

moderate risk

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