What is the E&M code for a follow-up office visit for an established patient with acute bronchitis on warfarin therapy?

E&M Code for Follow-Up Visit: Acute Bronchitis with Warfarin Therapy

This follow-up visit for an established patient with resolving acute bronchitis and routine INR monitoring should be coded as 99213 (established patient office visit, low to moderate complexity).

Coding Rationale

Key Components Assessment

For established patient office visits, only two of three key components (history, examination, medical decision-making) are required to determine the code level 1.

This visit demonstrates:

• Problem-focused to expanded problem-focused history: Follow-up of acute bronchitis with symptom review (persistent mild cough, medication effectiveness) 1

• Limited examination: Assessment of respiratory status and warfarin therapy monitoring 1

• Low to moderate complexity medical decision-making:

  • Management of resolving acute bronchitis with ongoing symptomatic treatment 2, 3
  • Warfarin monitoring with INR check (routine anticoagulation management) 4
  • Coordination of upcoming laboratory work 4

Medical Decision-Making Complexity

The complexity is low to moderate because:

• The acute bronchitis is improving and self-limited, requiring only symptomatic management with benzonatate 4, 2
• Routine INR monitoring for stable warfarin therapy represents straightforward chronic disease management 4
• No new problems or complications requiring extensive evaluation 1
• The patient completed prednisone therapy without complications 2

Why Not Higher Level Codes

99214 or 99215 would be inappropriate because:

• No moderate to high complexity decision-making is documented 1
• The bronchitis is resolving without complications (pneumonia ruled out, no bacterial superinfection) 4, 5
• Warfarin management is routine with scheduled monitoring already established 4
• No new diagnoses, significant changes in treatment plans, or acute complications 1

Clinical Context Considerations

Acute Bronchitis Management

The patient's improving clinical course is expected, as acute bronchitis typically resolves within 10-14 days with symptomatic treatment 4, 2. The persistent mild cough is consistent with normal disease progression 4.

Warfarin Monitoring

Routine INR monitoring does not elevate coding complexity when the patient is stable on an established regimen 4. The scheduled monthly INR appointments and consistent dosing pattern (varying doses on specific days) indicate stable anticoagulation management 4.

Antibiotic-Warfarin Interaction Note

While azithromycin was previously prescribed, the patient has completed therapy and the INR check today addresses any potential interaction risk 6, 7. This represents routine monitoring rather than management of a complication 6.

Common Coding Pitfalls to Avoid

• Do not upcode based solely on warfarin therapy: Routine anticoagulation monitoring in stable patients does not automatically warrant higher-level codes 4, 1
• Do not conflate multiple chronic conditions with complexity: The visit addresses one resolving acute problem and routine monitoring 1
• Do not code based on time unless counseling dominates >50% of the visit: No indication that counseling was the primary component 1
• Do not include scheduled future appointments in complexity assessment: Coordination of already-scheduled laboratory work does not increase medical decision-making 1