Provide the following answers for this coding scenario: 1) E/M Office visit CPT Code 2) Number and Complexity of Problems Addressed (Minimal, Low, Moderate, or High) 3) Amount and/or Complexity of Data to be Reviewed and Analyzed (Minimal, Limited, Moderate, or Extensive) 4) Risk of Complications and/or Morbidity or Mortality of Patient Management (Minimal, Low, Moderate, or High) Coding Scenario: History of Present Illness The patient is a 56-year-old female who presents to the office today with a history of diabetes mellitus, diagnosed 2 months ago. This is the first time I have met with the patient. She was admitted to a local hospital in October for necrotizing fasciitis, first noticed as a draining infection on her neck. On admission, her hemoglobin A1C was >15%, and she had significant hyperglycemia. She was started on insulin therapy with Lantus and Humalog. Since her discharge about 2 weeks ago, she notes her blood sugars have been dropping. She has cut back on both her Lantus and Humalog, down from 35 units of Lantus, now taking 24 units qhs. Her Humalog was decreased from 10 to 5 units with meals. She stopped taking glipizide on her own. She checks FSBG 3-4 times/day, and her fasting numbers are consistently 90-120. Pre-meal tends to be more variable, with some lows into the 70s, and highs in the 130s. She was having lows into the 40s before she stopped the glipizide. She has a non-healing ulcer on the bottom of her left foot, and she is worried about returning to work next week where she will need to stand on her feet. The ulcer is not painful, and has been present for several months (before the neck lesion). Her neck lesion is still draining, but she notes it is gradually healing. She denies increased thirst or urination, but in the past she has always been one to feel thirsty. She notes since all of this, she feels colder than usual and finds it difficult to get warm. She notes her blurry vision is improving. No chest pain. No bowel changes. No tremor. Review of Systems Please see HPI. All other systems are negative on a 10-system review. Past Medical History: Necrotizing fasciitis, type 2 diabetes mellitus and hypertension Social History: Married, never smoked or used smokeless tobacco, no alcohol use, no drug use Occupational History: Nurse Family History: Patient is adopted Physical Exa.m BP 121/70 | Pulse 97 | Ht 5' 3.5" (1.613 m) | Wt 145 lb 3.2 oz (65.862 kg) | BMI 25.32 kg/m2 | SpO2 98% Eyes: Extra-ocular movements intact. No exophthalmos. ENT: Moist mucus membranes. Dentition adequate. Neck soft, nontender without thyromegaly. No thyroid nodules appreciated. CV: Regular rate and rhythm, no murmurs Lungs: Clear to auscultation bilaterally without wheezes or crackles Abdomen: Bowel sounds present, non-tender, non-distended. No discolored striae. No lipohypertrophy. Skin: Neck lesion covered with a dressing with some drainage. Foot exa.m: There is a 0.5 cm lesion on the plantar left foot, which does not have erythema or pus draining, but has some serosanguinous drainage. The right foot has early callous formation as well. Sensory ex.am of the foot shows intact sensation, tested with the monofilament. Good pulses bilaterally. No onychomycosis. Skin dry, no interdigital fungal infection. Neuro: Reflexes symmetric and 2+. No tremor. Lab results: Lab results discussed with patient. HGB A1C 15.8 (H) Assessment and Plan 1. Type 2 diabetes, new onset, currently doing better with Lantus, Humalog and glipizide. Blood sugars are now trending low. -Continue Lantus 24 units daily, will adjust this to keep fasting blood sugar 90-130 -Decrease Humalog, taking 4 units with each meal if pre-meal blood sugar is >140 -Will repeat HGB A1C today 2. Dyslipidemia. -Will check lipid panel (non-fasting) today, but if abnormal, will need to check a fasting lipid panel