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Original Question

Please code the E/M code and any other procedures for the following case from your CPT coding book and add modifier if applicable: Location: New Hope Family Center Encounter Date: 01/18/xx Provider: Sue Code, MD Patient: Anita Services Gender: F Age: 50-year-old established patient Reason for the Encounter/Chief Complaint: Patient was a passenger in an public bus accident in which she suffered a broken pelvis, right wrist, root foot and closed fracture of the right femur. After surgical repair of the pelvis she was admitted to Family health Skilled/Rehabilitation Facility for physical therapy. After 6 months of rehab, she is ready for discharge. She will be discharged home to her husband and three sons. All areas appeared to have healed well with no pain or tenderness. Balanced weight-bearing. Time spent on discharge: 65 minutes.

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