Medical Insurance 7th Edition by Amy Blochowiak, Joanne Valerius, Nenna Bayes, Cynthia Newby

Exercise 31

1. In which category-problem focused, expanded problem focused, detailed, or comprehensive-would you place these statements concerning patient history? Why?
CASE A
Patient seen for follow-up of persistent sinus problems including pain, stuffiness, and greenish drainage over the past twenty days. She continues to have left-sided pain in the forehead and maxillary areas and feels that her symptoms are worse around dust. She gets drainage into her throat, which causes her to cough. Review of systems reveals no history of diabetes or asthma. She has thyroid problems for which she takes Synthroid.
CASE B
Patient presents with a mild case of poison ivy on face and both hands contracted four days ago while gardening; has never been bothered by poison ivy before.
2. 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
_______________________________________________________________
CASE B
Initial office evaluation by oncologist of a sixty-five-year-old female with sudden unexplained twenty-pound weight loss. Comprehensive history and examination performed with medical decision making of high complexity.
CASE C
Office visit by established patient for regularly scheduled blood test to monitor long-term effects of Coumadin; nurse spends five minutes, reviews the test, confirms that the patient is feeling well, and, after speaking with the physician on the medications, states that no change in the dosage is necessary.
3. If a physician sees a patient in the hospital and the patient comes to the office for a follow-up visit, is the follow-up encounter coded for a new or established patient?