Lbibian
Contributor
Would a medication management visit with these notes justify a level 5? I don't believe so, but one of my providers is challenging me
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Wiki Medication mgmt visit
- Thread starter Lbibian
- Start date
amyjph
True Blue
Would need the rest of the note to even code an E/M, we can't decide based only on the A/P. There is no chief complaint or reason for visit here.
Just looking at that, it's not a level 5 unless they correctly documented and coded by time with a # of minutes to support a 5. Otherwise, this is probably a 4. Looks like possibly 1 chronic, exacerbated and prescription drug mgmt.
Just looking at that, it's not a level 5 unless they correctly documented and coded by time with a # of minutes to support a 5. Otherwise, this is probably a 4. Looks like possibly 1 chronic, exacerbated and prescription drug mgmt.
Lbibian
Contributor
These are the provider's notes
amyjph
True Blue
I would ask the provider what the reasoning is and why they feel it's a level 5. This is not a 5 based on the documentation. Did this visit take 40 or more minutes and they forgot to document the visit based on time? That would be the only way.
This is Mod/None/Mod. 4.
This is Mod/None/Mod. 4.
Lbibian
Contributor
Thank you for the advice