The physician documents that the patient was seen for a sore…

The physician documents that the patient was seen for a sore throat and low-grade fever for two days. Although the patient had been gargling with warm salt water, it was not helping. What part of this documentation would be considered “modifying factors” in the history-of-present-illness documentation element?

What is the correct code assignment for destruction of two g…

What is the correct code assignment for destruction of two groups of internal hemorrhoids with use of infrared coagulation?   46250 – Hemorrhoidectomy, external, 2 or more columns/groups 46930 – Destruction of internal hemorrhoid(s) by thermal energy (eg. infrared, coagulation, cautery, radiofrequency) 46260 – Hemorrhoidectomy, internal and external, 2 or more columns/groups 46946 – Hemorrhoidectomy, internal, by ligation other than rubber band; 2 or more hemorrhoid columns/groups, without imaging guidance  

Office Visit Date of service: 9/28/20 Date of last treatment…

Office Visit Date of service: 9/28/20 Date of last treatment: 8/3/18The patient is seen for a chief complaint of shortness of breath and fatigue. The physician documents a medically appropriate history and examination. The problem is one undiagnosed new problem with uncertain prognosis. The physician ordered three unique tests with moderate risk. What is the correct E/M code for this service?

Office Visit Date of service: 1/3/21Date of last treatment:…

Office Visit Date of service: 1/3/21Date of last treatment: 2/12/19The patient was seen for a cough and sore throat. The physician performed a medically appropriate history and physician and established an impression and plan. The physician documents a 15-minute visit. What is the correct E/M code for this service?

A new patient was seen in the physician’s office for a rash…

A new patient was seen in the physician’s office for a rash across the lower back. The physician performed a medically appropriate history and examination, assessment and plan that includes a prescription. The time is documented as 35 minutes. What is the appropriate E/M service code? 99203 – New patient, Medically appropriate history and/or examination, Straightforward MDM, and 30-44 minutes spent with the patient 99202 – New patient, Medically appropriate history and/or examination, Straightforward MDM, and 15-29 minutes spent with the patient 99212 – Established patient, Medically appropriate history and/or exam, Low MDM, and 10-19 minutes spent with the patient 99213 – Established patient, Medically appropriate history and/or exam, Low MDM, and 20-29 minutes spent with the patient