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Medicine, 01.02.2021 06:30 andersonkee2657
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:
problem focused
Determine the extent of examination performed:
Determine the complexity of medical decision making:
complexity
CPT E/M code:
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Evaluation and Management Coding Practice:
S: Monica Sullivan was seen in the office by Dr. White o...
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