Question

Using the office visit E/M codes, which code would you select for each of these cases?

CASE A
Chart note for established patient:
S: Patient returns for removal of stitches I placed about seven days ago. Reports normal itching around the wound area, but no pain or swelling.
O: Wound at lateral aspect of the left eye looks well healed. Decision made to remove the 5-0 nylon sutures, which was done without difficulty.
A: Laceration, healed.
P: Patient advised to use vitamin E for scar prophylaxis

Answer 1

E/M (Evaluation and management coding is a coding process in medical billing. Practicing health care providers use this this to Medicare ,medicaid, private insurance reimbursement purposes. E/M codes are based on the current procedural terminology (CPT) codes established by American medical association. E/M codes given based on levels 1 to 5 codes from 99211 to 99215. Scoring should be based on levels.

Level	E/M code	History	physical examination	MDM(medical decision made)	Time
1	99211	none	none	none	5minutes
2	99212	problem focused	problem focused	straight forward	10 mins
3	99213	epf (Expanded problem focused	epf	low	15 mins
4	99214	detailed	detailed	moderate	25 mins
5	99215	comprehensive	comprehensive	high	40 mins.

An established patient is defined as someone who has been seen by physician in the same specialty with in the previous three years.

S. Patient returns for removal of stitches, placed seven days above , reports normal itching around the wound,no complaints of pain and swelling. Hear patient need for removal of sutures .For this E/M code is 99211 (CPT) code , it should only used by medical assistant or nurse when performing services such as wound checking, dressing, sutures removal. It never e billed for physician services. It is for established patient. For new patient we can use 99201 -99203 as E/M visit for sutures removal.

O. Wound at lateral aspect of left eye looks well healed. Decision made to remove 5-0 nylon sutures, which was done without difficulty. Hear also decided to remove sutures. Medical decision has made straight forward so code for this is 99212.

A. Laceration, healed. Its just observation done only took 5 minutes so code we can use 99212.

P. Advised to use vitamin E for scar prophylaxis ,it is expanded problem focused advise so we can use 99213 code for this.