E&M Coding

E&M Coding Scenario #1

A 55-year-old male (01/29/1957) presents with 20 minutes of chest pain with diaphoresis and mild nausea. He is treated with morphine IV by paramedics before and during transport to the ED. On arrival the to the ED, pain and other symptoms resolved.

  • Pain does not require treatment.
  • Heart rate is 75, BP is 150/92, and respirations 16 per minute. Temperature is normal and he is anxious but not agitated.
  • Workup
    • Lab tests including CBC, cardiac enzymes and electrolytes – cardiac enzymes drawn three times one hour apart
    • Portable Chest X-Ray
    • EKG – repeated at one hour after initial
    • Cardiologist contacted by phone
  • Disposition is home with office follow-up.

What is the expected E&M level?

E&M Coding Scenario #2

A 75-year-old female (01/29/1937) is brought to the ED from a nursing home because she fell and injured her right hip and shoulder. She has diabetes managed with multiple daily insulin injections.

  • Pain does not require treatment.
  • Vital signs are: temperature of 100, pulse rate of 134, respirations of 20, blood pressure of 160 over 100.
  • Workup
    • Nurse performs a bedside blood glucose test – result is elevated blood glucose
    • CT of the Abdomen is ordered and performed
    • X-Ray of the Pelvis and Shoulder ordered and performed
  • Disposition is Home

What is the expected E&M level?