Jenn asked in Science & MathematicsMedicine · 1 month ago

Medical Coders...help on this tricky E & M documentation (homework)?

I posted the documentation below... first having a hard time figuring out where my provider is..ER or inpatient initial hospital care? And secondly.. the level is hard to distinguish. Comp history and detailed exam w/ mod mdm. Do I back code because that isn't 3 out of 3 key components? Thanks! 

The 38-year-old patient is seeing the orthopedic provider today with neck and back pain in the ER. During a previous office visit last month with her PCP, the patient was diagnosed as having multiple areas of bulging discs. The patient is in extreme pain and is considered a surgical candidate at this time. Significant trauma in the past is noted, but C2-12 are intact. Deep tendon reflexes are within normal limits and symmetrical in the upper and lower extremities. Heart, lungs, and abdomen are without significant pathology. There are marked paravertebral spasms throughout the cervical, thoracic, and lumbar regions. HEENT: Patient has bilateral otitis externa noted. The orthopedic provider does an initial inpatient with a comprehensive history, detailed exam and moderate MDM.                      

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