E&M--How would you code this from progress note?


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82 yr old male in SNF established pt.

Seen @ req of DON to eval for use of anticholinestrase inhibitors.

HX unobtainable from pt (demtentia)

Meds reviewed: sulfa, codeine

exam: all areas examined; exceptions:
Neuro: Conf/disoriented. speech clear-inappropriate
Psych: flat affect
assessment/plan: dementia-advanced stages. riske of side effects + polypharmacy> benefit to tx. no indication of benefit to tx with anticholinesterase inhibitors @ this time. will check labs to r/o other reversable cx for decrease cognition. DC aricept. DNR. Cont care.
I would code this as a 99308. You need 2 of 3 components. For the exam I would use neuro and psyc that is a expanded prob focused. For the medical decision making you have a stable chronic illness, and they dc'd the Airicept. That is a low complexity. That makes this a 99308.