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

  1. Post E&M--How would you code this from progress note?
    Medical Coding Books
    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.

  2. #2
    Seacoast- Dover New Hampshire
    Default E&M on SNF
    I would say that this is straight forward exam.
    Karen Barron, CPC
    Hampton New Hampshire Chapter

  3. #3
    I would have to agree with Karen. It would be a straight forwarded.

    Kim Moore, CPC

  4. #4
    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.

  5. Default
    I came up with a 99308 as well.

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