Final answer:
A family physician may use various E/M services codes for a work disability evaluation, depending on case complexity. Additional tests and treatments would be based on the patient's disability and symptoms. Specific guidelines like a 'Clinical Focus box' help ensure evidence-based tailored care.
Step-by-step explanation:
When a family physician is performing a work disability evaluation, the E/M (Evaluation and Management) services that would be appropriate depend on the complexity and specifics of the case. An initial visit might be coded as a new patient visit (such as 99201), but for comprehensive evaluations or follow-up visits, higher-level codes like 99245 could apply if the documentation supports the level of service and the encounter requires significant time and complexity. After an initial assessment, the physician might order additional tests based on the nature of the disability and symptoms presented, which could range from imaging studies to specific functional assessments.
The type of treatment recommended by the doctor should be tailored to the nature of the work disability. Treatments might include physical therapy, medication, occupational therapy, or possibly referrals to specialists for more comprehensive management. In each case, the recommended treatment will take into account the patient's individual circumstances and the goal of optimizing function and facilitating a return to work, if possible.
To determine both the additional tests and types of treatment, the doctor might follow a 'Clinical Focus box' or specific clinical guidelines relevant to the case presented. Following these guidelines ensures that the evaluation and management are evidence-based and tailored to the individual needs of the patient.