Question

HIT 120

Evaluate the following E&M codes assignments for accuracy. Defend your answers and provide corrections if necessary.

1. The new patient was seen in the physician’s office and the physician documented an expanded problem focused history, detailed examination and medical decision making was of low complexity.

E&M code assigned: 99203

2. The established patient was seen in the physician’s office and the physician documented a detailed history and examination with medical decision of low complexity.

E&M code assigned: 99214

3. The new patient was seen in the outpatient clinic and the physician documented a detailed history, comprehensive examination and medical decision making of moderate complexity.

E&M code assigned: 99204

4. The physician visits an established patient in an assisted living facility and documents a detailed interval history and detailed examination with medical decision making of low complexity.

E&M code assigned: 99336

Answer 1

*E&M CODE 99203- The physician documented Not an EXPANDED PROBLEM FOCUSED HISTORY, DOCUMENTED "DETAILED HISTORY, DETAILED EXAMINATION, AND MEDICAL DECISION MAKING WAS THE LOW COMPLEXITY . EXPANDED PROBLEM FOCUSED HISTORY IS A " LOWEST LEVEL OF HISTORY", BUT DETAILED HISTORY IS " SECOND HIGHEST LEVEL OF HISTORY ". * E&M CODE 214-The Physician documented A DETAILED HISTORY AND EXAMINATION WITH MEDICAL DECISION OF NOT LOW COMPLEXITY, BUT MODERATE COMPLEXITY OF DECISION MAKING. _ LOW COMPLEXITY MEANS LOW RISK, MODERATE COMPLEXITY MEANS MODERATE RISK. *E&M CODE 204- The Physician documented NOT DETAILED HISTORY BUT DOCUMENTED COMPREHENSIVE HISTORY, COMPREHENSIVE EXAMINATION, AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. _ COMPREHENSIVE HISTORY REVEALS HIGHEST LEVEL OF HISTORY, DETAILED HISTORY REVEALS SECOND HIGHEST LEVEL OF HISTORY. *E&M CODE 99336-The Physician documented A DETAILED INTERVAL HISTORY AND A DETAILED EXAMINATION WITH MEDICAL DECISION MAKING NOT LOW COMPLEXITY, BUT MODERATE COMPLEXITY.