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Day 1 - A provider admits the patient to observation care for type 2 diabetes mellitus with hyperglycemia. The provider orders a HbA1c, a urine (microalbumin), and kidney function lab tests.
Blood sugar is high and poorly controlled. The provider discusses the case with the patient ' s endocrinologist. The provider prescribes an IV insulin drip, along with SQ insulin and keeps the
patient in observation overnight.
Day 2 - Patient is in observation care and the provider orders a blood glucose test. The patient ' s glucose levels have improved. The provider places an order for the dietitian to see the patient.
Provider
documents spending a total time of 25 minutes with the patient.
Day 3 - Patient has a blood glucose test. The patient ' s glucose level is back to normal. The provider documents spending 15 minutes with the patient. The provider discharges the patient.
What E/M coding is reported by the physician for the patient in observation care?
A 55-year-old female patient is diagnosed with renal cell carcinoma. She is having a resection of the affected kidney, a portion of the ureter, and rib resection, open aproach. The procedure is complicated due to a prior surgical procedure performed on the same kidney.
What CPT® coding is reported?