Wiki Determining the level of service

[avogel1]

Good morning. I have an established patient whose history is an EPF, detailed examination and straightforward decision making. We have to have 2 out of the three, but when this is not met how do I determine the level of service? Thanks!

 

[mitchellde]

Two out of three for an established patient for this a level 3. For established you can throw out the lowest, then of the two criteria left the lowest of the two. EPF history is a level 99213, if this were a new patient it would be a 99202

 

[avogel1]

Thank you! I wasn't sure if the MDM was the driving factor in this or not. I appreciate it!

 

[mitchellde]

Actually the diagnosis is the driving factor. If the visit level does not correspond with the diagnosis there could be an issue.

 

[avogel1]

The patient has controlled hypertension as stated in the HPI. They had a complete physical exam. There was no lab work ordered.

 

[mitchellde]

Unless this was an annual exam then a 99213 is about right.

 

[avogel1]

Right...this was not a yearly physical, but a follow up on their hypertension.