Question

1. Explain, in your own words, what details you need to determine an accurate E/M code

2. Create a scenario illustrating a physician providing an evaluation and management services in a skilled nursing facility. Include the diagnosis for which this procedure would be medically necessary.

3. Report the accurate CPT code or codes. Include any necessary modifiers.

Answer 1

1, E/M code service is a process of physician-patient encounters with five-digit CPT codes for making bills. there are basic components for evaluating E/M service include chief complaint, history of present illness, review of symptoms, history including past, family, social, examination, medical decision making. important three components are history, exams, medical decision making it has certain rules and regulations. guidelines from 1995 to1997 there will by many different. so physicians and coders should use one version only for documentation guidelines for an encounter and should not mix both.
2, 72 years old patient with acute stroke after discharge within 2 days period return to a skilled nursing facility for the rehabilitation program. the same physician has seen the patient and made face to face visits, with the medical decision making of high complexity during the service period.
It is a transcioinal care managment service
3,CPT code - 99496