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Thread: NEED HELP!!! How do you code this E/M?

  1. #1

    Default NEED HELP!!! How do you code this E/M?

    AAPC: Back to School
    Chief Complaint: New patient presents for a scheduled school age well child visit. The patient is an 11 year old male. Patient is accompanied by father. Parents have no specific concerns.
    Diet: Adequate amount of calcium intake. The child drinks 46 ounces of water per day. The source is city water. Currently eating age appropriate foods daily. Diet is appropriate for age. No eating disorders. Sleep: Sleep patterns are normal. No sleep disturbances experienced. Hearing screen: Able to hear 500 Hz, 2000 Hz and 4000 Hz at 25 dB HL in both ears. Behavior: Described as very good most of the time. Patient has no behavior problems. Has never been sexually active. Using age appropriate discipline and withdrawal of privileges as a form of discipline. Child does get along with parents and siblings and does chores. Patient is in the sixth grade. School performance is average. The patient is active. Anticipatory Guidance: No drugs or alcohol in the home. Standard anticipatory guidance and safety sheet given.
    HPI: Presents for physical exam. Patient feeling well. Immunizations will have to wait until shot records comes in.
    ROS: The patient denies constitutional symptoms, respiratory symptoms, gastrointestinal symptoms, male genital problems, and skin, hair and nail symptoms.
    Current Meds: none
    Allergies: NKDA
    Past Medical History: physical and dental exam in 2008. Eye exam in 2007.
    Family History: Unremarkable
    Social History: The home is smoke free. There is no history of abuse.
    Objective: BP: 98/78, Pulse: 72, Temp: 97.8, Ht: 59”, Wt: 117lbs, BMI: 23.6.
    Exam: Const: Healthy appearing child, well nourished and alert. Weight within the normal range for stated age. Communicates normally. Eyes: 20/20 in both eyes without correction. No discharge from the eyes. PERRL. Normal eye movement. ENMT: Auditory canals are patent. Tympanic membranes normal landmarks, no fluid or erythema bilaterally. Nasal mucosa shows moistness and normal color, but no discharge. Oral mucosa: pink, smooth and moist. Neck: supple, with no adenopathy. Resp: Respiration rate is normal. Lungs are clear bilaterally. CV: Rate is regular. Rhythm is regular. Pedal pulses: 2+ and equal bilaterally. GI: Abdomen is nondistended, nontender and soft. Bowel sounds normoactive. No palpable hepatosplenomegaly. GU: Normal genitalia. No hernias. Musculo: Spine: No scoliosis. Upper extremities: Strength: Normal and symmetric. ROM is physiologic. Lower extremities: normal and symmetric. ROM is physiologic. Skin: No rash or lesions. Neuro: Mood is normal. Affect is normal.
    Assessment and plan: Normal physical exam. Follow up prn.

  2. #2

    Default E/M level for a preventive exam

    This seems to be a well child exam(preventive). I would bill 99383 this is for a new patient for a child aged 11 years old.


  3. #3

    Smile Preventive Medicine E/M

    I agree with Kelsey -- should be a 99383 - Preventive medicine, new patient, age 5-11 years...

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