An 86-year-old woman at a nursing facility develops confusion and becomes combative. It is discovered that she has a urinary tract infection, which is causing her confusion. She has been in the nursing facility for five days already and the attending physician is called in to assess the patient and manage her care. He comes and does a detailed interval history, a detailed examination and moderate-complexity medical decision making, spending about 25 minutes with the patient and writing orders. What is the correct evaluation and management code for this patient?
Explanation
Answer: C - 99309 is the correct code for the care of this patient within a nursing facility. A detailed interval history was performed because the previous history was five days old, a detailed examination was performed and the physician spent 25 minutes with this patient either at the bedside or on the patient’s unit making up a plan of care for her.
Code 99307 is incorrect because this code is for a problem-focused interval history, a problem-focused examination and straightforward medical decision making, spending 10 minutes or fewer during the encounter. Code 99308 is incorrect because this code is for an expanded problem-focused interval history and examination as well as low-complexity medical decision making, taking about 15 minutes of time. Code 99310 is incorrect because this code is for a comprehensive history and examination as well as high-complexity medical decision making typically taking 35 minutes, which is longer than this physician spent with this patient’s evaluation and management.
