Reference no: EM133450279

Assignment:

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 and documented. During this visit, the physician found a mass in the abdomen and scheduled an abdominal CT scan, and he wrote orders for blood work and a urinalysis. The physician performed and documented a separate medically appropriate history and exam and low-level of medical decision-making.

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.