A 56-year-old female patient sees her physician for the first time for a variety of medical problems.  She was diagnosed 4 years ago with insulin-dependent diabetes mellitus with complicating eye and renal problems.  In addition, she suffers from hypertensive heart disease with episodes of congestive heart failure.  Her peripheral vascular disease has worsened, and she can walk only a block before being crippled with extreme leg pain.  The patient reports that a new problem has surfaced: throbbing headaches with radiating neck pain.  The physician thoroughly discusses her health concerns and issues.  In order to manage and investigate the multiplicity of problems, the physician takes a complete PFSH.  A complete ROS is performed and comprehensive physical exam is completed. The physician has to take a multitude of factors into consideration, and documents a high level of medical decision-making, as the patient's problems are highly complex.  

What is the E/M code used to report this service? Use modifiers as appropriate.

Answer rating: 100% (QA)

The appropriate EM code for this service will depend on the level of complexity and e... View the full answer