EM Coding: Case Studies
Join our community on Telegram!
Join the biggest community of Pharma students and professionals.
Here are some more examples of Evaluation and Management (E/M) coding scenarios:
Case Study 6: Outpatient Clinic Visit
Scenario: A 45-year-old female patient visits an outpatient clinic for a follow-up regarding her diabetes and hypertension. The physician reviews her current medications, orders lab tests, and adjusts her treatment plan.
Question 6: Assign the appropriate E/M code for this outpatient clinic visit.
Case Study 7: Inpatient Hospital Visit
Scenario: A 60-year-old male patient with chronic obstructive pulmonary disease (COPD) is admitted to the hospital due to worsening symptoms. The physician conducts a detailed history, comprehensive examination, and makes changes to the patient's medication regimen.
Question 7: Assign the appropriate E/M code for this inpatient hospital visit.
Case Study 8: Initial Nursing Facility Assessment
Scenario: A 75-year-old female patient is admitted to a nursing facility for long-term care. The physician performs a detailed assessment of her medical conditions, reviews her medical history, and develops a comprehensive care plan.
Question 8: Assign the appropriate E/M code for this initial nursing facility assessment.
Case Study 9: Consultation with a Specialist
Scenario: A 55-year-old male patient is referred to a cardiologist for evaluation of chest pain. The cardiologist conducts a comprehensive history, a detailed examination, and orders additional cardiac tests.
Question 9: Assign the appropriate E/M code for this consultation with the cardiologist.
Case Study 10: Emergency Room Visit
Scenario: A 30-year-old female patient comes to the emergency room after experiencing a severe allergic reaction to a medication. The physician performs a detailed examination, administers emergency treatment, and prescribes medications.
Question 10: Assign the appropriate E/M code for this emergency room visit.
Case Study 11: Preventive Medicine Service
Scenario: A 50-year-old male patient visits his primary care physician for a routine annual check-up. The physician performs a comprehensive history, physical examination, and orders preventive screenings.
Question 11: Assign the appropriate E/M code for this preventive medicine service.
Case Study 12: Prenatal Care Visit
Scenario: A pregnant patient in her second trimester visits her obstetrician for a prenatal check-up. The obstetrician reviews her medical history, performs a comprehensive examination, and discusses the baby's development.
Question 12: Assign the appropriate E/M code for this prenatal care visit.
Remember, each E/M code has specific documentation requirements, including the level of history, examination, and medical decision-making involved in the encounter. Proper documentation is crucial for accurate coding, billing, and reimbursement. Always consult the latest CPT codebook and any relevant guidelines when assigning E/M codes.
