Milestone Three - CPT and EM

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Southern New Hampshire University *

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215

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Mechanical Engineering

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Apr 3, 2024

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CPT and E/M 1 Milestone Three: CPT and E/M Kelli Flanagan Southern New Hampshire University HIM 215 – Coding & Classification Systems Professor Donna Leone 01 October 2023
CPT and E/M 1 When reviewing Ms. Lates medical record, I came upon several procedures that were performed based on her signs and symptoms present during her recent visit to the ED (Emergency Department). I went through each specialty and found the reports that confirmed the tests were performed as the doctor ordered, as well as the documentation from the ED physician. The procedures I found within the patient’s record to be coded for are the EKG, urinalysis, CBC differential, x-rays of the left hip and chest, and the E/M of the patient at the ED. I chose the CPT codes in conjunction with their specialty service. So, for Laboratory reports, I confirmed tests for CBC Differential and urinalysis were performed. When I searched the term CBC in SelectCoder, several codes were returned. I determined the most appropriate code to be 85025, because it also includes the automated differential. Several results were also returned for urinalysis. I felt the CPT code that best fit this test was 81000, which is for urinalysis with dipstick with microscopy, non-automated. Next I came to the radiology report section of the medical record. X-rays were performed on the left hip as well as the chest. The CPT code I chose for the hip x-ray is 73502, which is for unilateral hip with 2-3 views, as two views were taken, which included the anteroposterior and lateral aspects of the left hip. The CPT code I chose for the chest x-ray is 71046, which is a radiologic exam of the chest with two views, whiich were also anteroposterior and lateral aspects of the chest. I next came to the EKG (electrocardiogram) report which was reviewed and approved by a physician. The CPT code I chose for this procedure is 93000. This code is appropriate for routine 12-lead EKG’s that are reviewed by a physician, include an interpretation, and include a report. When I browsed for codes in CPT under evaluation and management (E/M), I found the most
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