Although there are seven components for the levels of evaluation and management (E/M) services, most encounter levels are coded on the basis of the history, examination and medical decision making (MDM), which are the key components extracted from documentation in the medical record. However, when counseling and coordination of care for a patient are the…
Clinical Vignette A 45-year-old woman with long-standing asthma and chronic sinusitis has new-onset peripheral neuropathy, arthralgias, fatigue, progressive dyspnea and a nonproductive cough. She has never smoked and has no environmental exposures. Her medications include an albuterol metered-dose inhaler (which she uses daily); an inhaled corticosteroid, montelukast; and ibuprofen (which she takes occasionally). She is…