Reference no: EM133909645

Question

Chief Complaint: Nursing facility visit for 87-year-old female patient. HPI: Yesterday, the patient fell out of her wheelchair while briefly left unattended. She has a small laceration on her left arm and bruising to left arm, wrist and hand. She has a small bump on her forehead and has complained of headache since the accident. She states that she has felt dizzy and lightheaded. No nausea or vomiting. No seizures. She has refused medication for pain. PMH: She has no history of prior head trauma. Patient is not currently on any medications. GENERAL: AOx2, patient is in her bed. EYES: PERRLA, +direct and consensual pupil response. EOM intact, 20/20 vision bilaterally without correction. No strabismus, no nystagmus. Fundoscopic exam normal, vessels intact, optic disc with clear margins. Nares patent with no edema or erythema. Uvula midline, palate rises symmetrically. Tongue midline with no fasciculations. HEAD: 2cm x 1cm oblong left frons about 2cm above eye. Ecchymosis visible on hematoma. +tenderness. EARS: Clean canals bilaterally, TMs visualized, +light reflex, no erythema or edema bilaterally. SKIN: Warm, dry, no rashes. 1.5 cm superficial laceration on left arm. Contusions to LUE, including wrist and hand. NEURO: CN II-XII grossly intact. DTRs all 2+. Dull and sharp sensation intact. Position sense intact. Stereognosis and graphesthesia sense intact. Two-point discrimination sense intact. MMSE total 19 (Orientation to time 5/5, orientation to place 5/5, immediate word recall 1/3, serial sevens 3/5, delayed word recall 0/3, language 2/3, repetition of phrase 1/1, 3-part command 2/6) ASSESSMENT AND PLAN: No further evaluation at this time. Continue to monitor and call my office if symptoms persist or worsen.

What is the correct CPT code E/M encoder?