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Coding Corner Question: February

  |  Issue: February 2014  |  

Assessment:

  1. Rheumatoid arthritis: stable on chronic medicine
  2. Osteoporosis: stable on chronic medicine

Plan:

  1. The patient will start tumor necrosis factor inhibitor. The physician held a lengthy discussion with the patient concerning risks and benefits. A skin test and chest X-ray were performed for tuberculosis screen. Labs were drawn for disease evaluation and medication monitoring. The patient is to continue all other medicines.
  2. Osteoporosis: A dual-energy X-ray absorptio­metry scan was due and was ordered to reassess the patient’s osteoporosis. The patient is to continue Fosamax, calcium, and vitamin D.
  3. Labs were performed to check the toxicity level of the drugs. Complete blood count, comprehensive metabolic panel, erythrocyte sedimentation rate, C-reactive protein, and a hepatitis panel were ordered, due to the disease and medicines.

What level is the medical decision making for this E/M visit? Click here for the answer

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