Reference no: EM133536711
When coding in the real world, coders often have to consult with a coding manager or lead coder when there are questions that arise. Read this article called "Coding Grand Rounds: Creating a Learning Culture."
For this discussion, let's put this idea into practice for Evaluation and Management coding.
After reading the article, discuss one concept in the article and how you see this as beneficial to your role as a coder.
Review the following two scenarios. You will code both scenarios. No further explanation is needed, just provide the codes for each scenario.
Scenario 1
A 60-year-old male established patient saw his physician for a routine physical examination, and this was completed. During this visit, the physician found a mass in the abdomen. The physician finds an abdominal mass significant enough to schedule an abdominal CT (Computed Tomography) scan and to perform medically appropriate history and/or examination and medical decision-making of moderate complexity. The physician ordered the CT, CBC, and liver enzyme. The physician also documented all components required for the routine physical, including the orders for routine labs and a urinalysis. The patient will return for follow-up after the CT scan.
Scenario 2
Dr. Smith admitted a patient to observation care services after seeing him in the emergency department with severe nausea, vomiting, and dizziness from dehydration. The initial observation services documentation supported a comprehensive history, comprehensive exam, and moderate complexity medical decision-making. IVs were started, and the plan was to hydrate the patient and discharge him home the next morning. The patient, however, had not improved enough the next day (day two) and was observed for an additional 24 hours. The subsequent care documentation supported a problem-focused examination and low-complexity medical decision-making. On day three, the physician spent 45 minutes with the patient. Documentation supported an observation care discharge service, and the patient was discharged home.