Evaluation and Management Coding Practice: Ginny Tallman is a 73-year-old female who is followed in the Medical Clinic for COPD. Her medications include Theo-Dur 300 mg by mouth daily in the morning. History of present illness reveals that she seems to have adequate control of her bronchospasm using this medication. She also uses an albuterol inhaler two puffs p. o. q6h. She has no recent complaints of acute shortness of breath and no chest tightness. She has a chronic, dry cough, productive of scanty sputum. At this time, she is complaining of shortness of breath. PE reveals an elderly female in no real distress. BP in the left arm, sitting, is 110/84, pulse 74 per minute and regular, respiratory rate 12 per minute and somewhat labored. Lungs reveal scattered wheezes in both lung fields. There is also noted an increased expiratory phase. Cardiovascular exam reveals no S3, S4, or murmurs.

The impression is COPD with asthmatic bronchitis. The patient will have present medications increased to Theo-Dur 300 mg by mouth daily in the morning and 400 mg by mouth each evening. She should receive follow-up care in the clinic in approximately two months' time.

E/M category/subcategory: Office or Other Outpatient Services, Established Patient

Determine the extent of history obtained:
problem focused

Determine the extent of examination performed:

Determine the complexity of medical decision making:

CPT E/M code:

Cj is a 53 year old african american female presenting to pharmacy for first-time certification and cmr so that she may start getting her medications at no cost. cj states that her main concern about her health is her diabetes. pmh: t2dm, htn, hyperlipidemia sh: denies tobacco and illicit drug use, occasional alcohol use (1-2 drinks/month) fh: unknown allergies: penicillin (unknown reaction; had reaction when young). medications: lisinopril 5 mg daily aspirin 81 mg daily simvastatin 20 mg daily wt 231 lbs (105 kg), ht 5’6”, bmi 37.3 (obese), ibw 59.3 kg, bp 145/80, hr 98, random blood glucose 395, a1c 11.2%, estimated 10-year ascvd risk 9.5% drug-related problems: 1. uncontrolled t2dm 2. uncontrolled htn 3. suboptimal statin intensity 1) identify two pieces of objective data included in this case: 2) what kind of monitoring needs performed for the new prescription for this patient? 3) based on your case how would you counsel the patient on the new prescription medication? provide examples of specific aspects you would include in your patient education. 4) review your patient case. identify any medications that do not have a corresponding disease state. 5) review your patient case. identify any disease states are not treated by current medications. 6) what otc (over the counter) product would you recommend for this patient (based on the patient request for an otc product? include dose, frequency of administration, route of administration, and critical counseling points.