Evaluation and Management Coding Practice:
S: Monica Sullivan was seen in the office by Dr. White on 12/13 for the second time. She presented with a chief complaint of dizziness and weakness; she stated that she wanted to have her blood pressure checked.
O: Patient has been on Vasotec 5 mg and Hydrodiuril 25 mg. BP has been going up at home. Patient has felt ill, weak, and dizzy, with headache for three days. Cardiovascular exam was normal. BP of 130/110 and pulse rate of 84. Her temperature is 98.6°F and normal.
A: Accelerated hypertension. Bell's palsy.
P: Increase Vasotec to 5 mg a.m. and 2.5 mg p.m. SMA & CBC.
E/M category/subcategory: Office or Other Outpatient Services, Established Patient
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