You Be the Coder:
Tone Down E/M for Non-Complicated Revisits
Published on Tue Apr 05, 2016
Question: Our pulmonologist recently saw an established pneumonia patient. Her office visit note says: CC: Resolving pneumonia.
Pt here today for recheck. Pt diagnosed with pneumonia 11/09. Last CXR 12/7/15 showed minimal infiltrate in rt lower lobe. No coughing, SOB. Lungs: Clear to auscultation.
Resolving pneumonia. Patient has finished medication. Repeat CXR.
What level of E/M should I [...]