Abstracting and Coding an Evaluation and Management Report
A coder reads the following documentation in the patient record: “Mrs. Smith presents with a sharp pain in her right arm. She indicates that the pain is a 7 on a scale of 1 to 10. She says that the pain began 3 days ago after she spent several hours gardening. She says her arm has hurt constantly since then. She tried using a heating pad on her arm at night, which did not alleviate the pain. There has been some dizziness associated with these episodes.” What information within this description will be important for the coder to note in assigning the correct code for the patient’s history of present illness?