tci E/M Coding Alert - 2019 Issue Q3

Reader Question: Use This Documentation for Medication Checkup E/M

Question: Our provider saw a patient with GERD and started her on esomeprazole. The patient came back two weeks later, and the nurse evaluated her, taking blood pressure and other vitals. She also asked the patient if she had experienced side effects since she started on the medication. The patient reported that she vomited several times immediately upon starting the medication, but that she felt fine since then. The nurse recorded that information in the record and advised the patient to stay on the medication and to alert the practice if the vomiting or any other side effects return...

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