EM Coding Alert

Find out if your 2021 office/outpatient E/M savvy is up to speed.

If you’re still a little shaky on the way you’ll be using medical decision making (MDM) to calculate office/outpatient evaluation E/M levels this year, don’t worry. Here are three scenarios for you to practice on.

Simply open up the American Medical Association’s (AMA’s) medical decision making (MDM) table at www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf, read it through, then see what MDM level and office/ outpatient E/M code you would assign to each scenario.

Question 1: An established 2-year-old patient presents with a nosebleed that began several hours earlier according to the patient’s mother, who is the historian. The pediatrician examines the patient’s nostrils and finds a small foreign body in one of them. Assessment and Plan: Dx: epistaxis; foreign body, nose. The pediatrician removes the foreign body with forceps, then packs the patient’s nose with gauze, which is left in the patient’s nostril for 30 minutes. The pediatrician tells the mother to call if the patient’s nose bleeds again.

Question 2: A new 13-year-old patient presents with symptoms of asthma that occur daily and interfere with his ability to lead a normal life. This is confirmed by the patient’s mother, who is present at the encounter and adds to the history. The pediatrician administers a pulmonary function test (PFT), which records a forced expiratory volume in 1 second (FEV₁) of around 80 percent. Assessment and Plan: Dx: Asthma, unspecified. The pediatrician orders an albuterol inhaler and explains its use, then arranges a follow-up appointment to monitor the condition.

Question 3: An established female patient sees the pediatrician saying that she was experiencing fatigue and weight loss. The pediatrician determines the patient’s conditions are due to stress. Assessment and Plan: Dx: Moderate depression. The pediatrician administers and reviews a patient health questionnaire (PHQ). The pediatrician tells the patient she should talk with a counselor and asks the patient to sign a contract stating that she will not hurt herself. The pediatrician also asks her to call for any help should she get more depressed or have an anxiety attack and discusses medication possibilities in the future if needed. Total time spent in the visit, including review of the PHQ test, is 31 minutes.

Think you know the answers? Click the link and find out! https://www.aapc.com/codes/coding-newsletters/my-evaluation-management-coding-alert/coding-quiz-answers-check-your-answers-to-our-mdm-coding-quiz-166032-article