It can be difficult to translate the E/M rules into patient scenarios. The guidelines seem great in theory, but how does a clinician use them and select the correct level of service?

Here are ten examples. They represent the common visits in medical practices and health centers.
EXAMPLE ONE

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  Patient presents at the urging of a neighbor for a 1 cm by 1 cm red rash on his arm. Assessment: “Red area on arm. No concerns. Use moisturizing cream.”

EXAMPLE TWO

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  Patient complains of heartburn of 2-week duration, mild severity. Assessment: GERD, OTC medications.