Wiki Dealing with Peds E/M

[daniel]

Seeking guidance, Does this sound right. Auditing a physicians notes. The note reads to me, a 12yr old with new prob. Pharyngitis. No HPI, but we have Exam on TM. Documented with some detail. And lungs, also documented with some detail. With a prescription of Keflex. Does this qualify for a level four. Keep in mind this is an Establish patient.

So we got: Establish Patient
2 detailed body areas examined
New Prob
Prescription Drug given.

Using the 1995 guidelines, do we come up with a level four.
Need input.

Daniel
CPC

 

[liny]

in the Er as long as you have an HPI Ros and Exam your covered but the risk is low here so a level 3 for giving the persription or if he did x-ray but if his temp was above 104 then you can give a level 4 or IV anything was givin

 

[bigredcag]

from what you stated i came out with a level 3 too.
mdm is level 4 but exam is level 3 history was a level 2. so to meet 2/3 it would be a 3
good luck.