ME1160 Medical Record - A 10-year-old established patient

Question: .Medical Record: (**E/M code range: 99213-99215)

A 10-year-old established patient presents today for well child check with mother. The patient has two sisters and sees dad sporadically. Lives in a smoke free environment. 1 dog, 1rabbit.

Patient going into fourth grade with good grades. No parental concerns. Patient cooperates but does tend to back talk. Doing well on Concerta.

Examination of systems normal.

Counseled patient on the use of seat belts, bicycle/skate helmets, gun safety, water/sun safety.

Assessment:Well Child Check, ADHD,

Plan: Refill Concerta 18 mg PO q AM

Answer 3 question:

1. Describe the steps you would take to find the correct code for this case.
2. Assign the procedure code and explain why you chose the code that you did.
3. What affect did the E/M guidelines have on your choice of code? Explain how you used the guidelines.