Forum - Questions & Answers

Apr 15th, 2016 - dianawalp 1 

E/M level coding challenge

Pt last seen 13 months prior
Complaint: Foreign Body Sensation getting worse
light sensitivity, burning, sandy-gritty

HPI: HX corneal abrasion, HX eye pain/tearing, blurry vision, veils, HX eye infections, HX white film temple = total 5
Medical: Arthritis, Diabetes, Heart Trouble, High Cholesterol, HTN, Thyroid = total 6
Systemic SX HX: two (2) Heart surgeries, Stints
Systemic Family HX: Arthritis Mother, DM Father, Heart DZ Father, HTN Father, Thyroid DZ Mother
Systemic Medications: = total 15 (All Prescription)

Review of Symptoms: pt has existing Allergy, Cardiovascular, Constitutional, Endocrine, Musculoskeletal

Services performed: B/P, External, Slit-Lamp, Surgery-OP Report- Corneal Foreign Body

Assessment: Corneal Foreign Body. Initial Encounter, Right eye corneal scar, Retina - Vascular Bilateral, Systemic-Bilateral HTN w/o Retinopathy

Plan- RX Ciloxan, Artificial Tears, RTO later date for dilated evaluation
Time spent with patient: 45 - 60 minutes.

Justifiable to bill as 99215?



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