Assigning Evaluation and Management (E/M) Codes 1. Initial consultation is performed for a 78-year-old woman with unexplained weight loss, abdominal pain, and rectal bleeding. A comprehensive history and examination is performed. 99205 is the best code. The reason for her consultation is that she is having unexplained weight loss, abdominal pain, and rectal bleeding. There is a high MDM, Multiple DX, several tests, and she is considered high risk. The consultation and exam were comprehensive as well the patient history. 2. A 30-year-old patient presents complaining of flu-like symptoms characterized by unremitting cough, sinus pain, and thick nasal discharge. An examination reveals bronchitis and sinus infection. The patient is prescribed a 5-day course of Zithromax. 99202 is the bed code. This is a new patient office visit. The expanded problem is focused because the patient has 2 or more conditions. The treatment is straight forward. 3.
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