Question

dr. inez discharges mr. blancos from the pulmonary service after a bout of pneumococcal pneumonia. she spends 45 minutes at the bedside explaining to mr. blancos and his wife the medications and ippb therapy she ordered. mr. blancos is a resident of the shady valley nursing home due to his advanced alzheimers disease and will return to the nursing home after discharge. on the same day dr. inez re - admits mr. blancos to the nursing facility. she obtains a medically appropriate history, a medically appropriate examination and the medical decision making is moderate complexity. what is/are the appropriate evaluation and management code(s) for this visit? o 99238 o 99239 o 99239, 99305 o 99238, 99305

Explanation:

Step1: Identify key - factors

The patient has pneumonia, advanced Alzheimer's disease, and is being re - admitted to a nursing facility with moderate complexity decision - making.

Step2: Recall evaluation and management (E&M) code criteria

For a moderate complexity E&M service in an inpatient or observation setting, codes 99238 and 99239 are relevant. Code 99238 is for initial hospital care, and 99239 is for subsequent hospital care. Since this is a re - admission, we consider the subsequent care. Also, we need to account for the medical decision - making complexity.

Step3: Select appropriate codes

The appropriate evaluation and management code for a subsequent hospital care with moderate complexity decision - making is 99239. Additionally, we may consider a code for the specific condition like 99305 for the evaluation of a chronic condition (Alzheimer's disease).

Answer:

99239, 99305