Reference no: EM133883826

Assignment:

CPT Evaluation and Management Coding - After reviewing Jane Smith's documentation and the CPT Evaluation and Management (E/M) guidelines (located in the front section of your CPT coding manual), answer the following questions.

1. What is the appropriate CPT evaluation and management (E/M) code if it's determined based on the time spent?

2. What is the appropriate CPT evaluation and management (E/M) code when determining it based on the level of Medical Decision Making?

3. What is the accurate E/M code for Jane Smith's visit with Dr. Wells?

4. Explain how you determined the E/M code. Provide a step-by-step breakdown of how you coded the encounter and explain why this E/M code is accurate (referring to E/M guidelines and Table of Medical Decision Making (MDM)). The medical decision-making was moderate because managing cancer treatments and ordering a PET scan is complex. The doctor took a thorough history and did a detailed exam for the recurring cancer, which supports using a time-based coding method. In short, coding for a returning cancer patient reflects the comprehensive visit and the complexity of medical decisions. Using CPT code 99214 accurately captures the visit's complexity and ensures proper reimbursement according to E/M.