Greetings All,
I am wondering what level E/M code you would use for this case?
CHIEF COMPLAINT: Right eye pain.
SUBJECTIVE: This is a pleasant, 45-year-old male with a remote history of corneal ulcers from his contacts. He presents with a 2-day history of right eye sensitivity, photophobia, a little bit of mattering this morning. He does wear contacts. He threw them away yesterday. He said he had
them in for a month-and-a-half. It feels "grainy."
PAST MEDICAL HISTORY: As above. He is on Toprol and Lotensin presumably for hypertension.
REVIEW OF SYSTEMS: As above.
PHYSICAL EXAMINATION: Vitals are stable. Visual acuity of 20/50 OD 20/25 OS. On examination, nothing is seen grossly. The eyelids are reverted and nothing was seen. After tetracaine analgesia and fluorescent staining upon slit visualization, there is indeed uptake of a fluorescent between 2 and 3 o'clock right at the edge of the cornea.
ASSESSMENT: Corneal abrasion OD due to contact lens
PLAN: I told him no more contacts until he sees his physician. I did place some cyclogel and wrote a prescription for some gentamicin drops. I did not patch at this point but wanted him to see his eye doctor.
I am wondering what level E/M code you would use for this case?
CHIEF COMPLAINT: Right eye pain.
SUBJECTIVE: This is a pleasant, 45-year-old male with a remote history of corneal ulcers from his contacts. He presents with a 2-day history of right eye sensitivity, photophobia, a little bit of mattering this morning. He does wear contacts. He threw them away yesterday. He said he had
them in for a month-and-a-half. It feels "grainy."
PAST MEDICAL HISTORY: As above. He is on Toprol and Lotensin presumably for hypertension.
REVIEW OF SYSTEMS: As above.
PHYSICAL EXAMINATION: Vitals are stable. Visual acuity of 20/50 OD 20/25 OS. On examination, nothing is seen grossly. The eyelids are reverted and nothing was seen. After tetracaine analgesia and fluorescent staining upon slit visualization, there is indeed uptake of a fluorescent between 2 and 3 o'clock right at the edge of the cornea.
ASSESSMENT: Corneal abrasion OD due to contact lens
PLAN: I told him no more contacts until he sees his physician. I did place some cyclogel and wrote a prescription for some gentamicin drops. I did not patch at this point but wanted him to see his eye doctor.