Medical Insurance 7th Edition by Amy Blochowiak, Joanne Valerius, Nenna Bayes, Cynthia Newby

Exercise 22

Refer to Figure 6.4 on pages 207-208 and read the instructions for Outpatient, Consults, and ER at the top of page 208 and for the established patient section at the right. The instructions state: "If a column has 2 or 3 circles, draw a line down the column … and circle the code." In other words, for the established patient, it is not necessary to document the same level for all three components-history, examination, and decision making-to verify the code.
A. Why is this the case?
B. What code is correct for an established patient with a PF (problemfocused) result in the History column, an EPF (expanded problemfocused) result in the Examination column, and an L (low) result in the Complexity of Medical Decision Making column?
FIGURE 6.4 Example of Evaluation and Management Code Assignment Audit Form