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Evaluation and Management Coding (E/M Code)
The patient visited the clinic complaining of pain and redness to the left foot and with a history of diabetes. Following an assessment of the patient’s condition and his clinical history, he was diagnosed with cellulitis in addition to type 2 diabetes. Given the patient’s history of diabetes, he is at high risk of developing MRSA and/or osteomyelitis secondary to skin infection. The treatment and management of this patient’s condition require the use of an appropriate evaluation and management coding (E/M code). An E/M code is an important part of the management of cellulitis in patients with diabetes since it is critical to making the correct diagnosis, which in turn influences the treatment approach (Sullivan, 2018). In essence, giving an appropriate E/M code for the patient’s condition is essential to avoid under or overtreatment with antimicrobials, which remains is a major challenge in the management of cellulitis.
ICD-9-CM codes are given to different diabetic foot infections depending on various factors and symptoms. The evaluation and management code that would be given to the patient’s condition is ICD-9-CM 682.7. According to Krive et al. (2015), this code is given to conditions involving cellulitis and abscess of foot, except toes. This code was determined as appropriate for the patient’s condition because it involves cellulitis of foot not toes. The patient’s chief complaint is pain and redness on the left foot while the assessment shows cellulitis of foot. Therefore, the patient’s primary diagnosis based on the presenting symptoms is cellulitis of foot, which implies that ICD-9-CM 682.7 code is an appropriate E/M code. Moreover, the code was determined on the premise that the patient’s physical exam did not show any musculoskeletal deformities. However, there were no modifiers relevant to the patient’s visit to the clinic. Despite having a history of type 2 diabetes, the patient’s chief complaint was adequate for E/M code since there was no separately identifiable issue during the visit.
References
Krive et al. (2015, May). The Complexity and Challenges of the ICD-9-CM to ICD-10-CM Transition in Emergency Departments. The American Journal of Emergency Medicine, 33(5), 713-718.
Sullivan, T. (2018, April). Diagnosis and Management of Cellulitis. Clinical Medicine, 18(2), 160-163.
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