Probably going to Clinic Eight was the bedt thing to do given the fact that it was an ER case. Considering the type of medical insurance and coverage ( in USA?) and the recommended follow up ( given by Dr. Howitzer) there could be a number of causes and effects, being them neurological or not
The appropriate diagnosis and E/M code for this visit is 99214, R55
Dr. Howitzer sees Mrs. Jones in Clinic Eight for sudden loss of consciousness while watching the Olympic Torch go by. He is a new provider to the neurology department. Dr. Drake Rinaldi, a prominent member of the neurology faculty at the university saw Mrs. Jones last month. Dr. Howitzer performs a history including 3 HPI elements and 2 ROS, a detailed exam and has medical decision making of high complexity. The final diagnosis given is transient loss of consciousness. The patient makes a follow-up appointment to see Dr. Rinaldi in one week.
The appropriate diagnosis and E/M code for this visit is 99214, R55
E/M is “evaluation and management”. E/M coding is the process inwhich physician-patient encounters translated into five digit CPT codes to facilitate billing.
R55 is (Fainting) . Although the MDM complexity is at the level of code 99214, the history and examination were at the level of code 99213, because two of the three key components must be documented in order to use 99213.
Hope it helps!
Grade: 9
Subject: PO (health)
Chapter: the neurology
Keywords: Olympic Torch, E/M code, diagnosis, consciousness, the neurology faculty
