Medicine College

Evaluation and Management Coding Practice:

S: Monica Sullivan was seen in the office by Dr. White on 12/13 for the second time. She presented with a chief complaint of dizziness and weakness; she stated that she wanted to have her blood pressure checked.

O: Patient has been on Vasotec 5 mg and Hydrodiuril 25 mg. BP has been going up at home. Patient has felt ill, weak, and dizzy, with headache for three days. Cardiovascular exam was normal. BP of 130/110 and pulse rate of 84. Her temperature is 98.6°F and normal.

A: Accelerated hypertension. Bell's palsy.

P: Increase Vasotec to 5 mg a.m. and 2.5 mg p.m. SMA & CBC.

E/M category/subcategory: Office or Other Outpatient Services, Established Patient

Determine the extent of history obtained: BLANK problem focused

Determine the extent of examination performed: problem focused

Determine the complexity of medical decision making: moderate complexity

CPT E/M code: 99212

*Please answer the "BLANK" word

Answers

Answer 1
I believe it’s the answer “determin the extent”
Answer 2

Monica Sullivan was seen in the office by Dr. White on 12/13 for the second time, so here The blank word is "problem focused," as an evaluation and management (E/M) visit is a crucial factor in determining the appropriate level of E/M coding.

What is a problem-focused health service?

Monica Sullivan's history was problem-focused in this case, as the doctor only obtained information related to her primary complaints of dizziness and weakness; later, it was also problem-focused, as the doctor only performed a cardiovascular exam and took the patient's blood pressure, pulse rate, and temperature.

Hence, Monica Sullivan was seen in the office by Dr. White on 12/13 for the second time, so here The blank word is "problem focused," as an evaluation and management (E/M) visit is a crucial factor in determining the appropriate level of E/M coding.

Learn more about the problem-focused health service here.

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