E/M level quandry

b10sliger

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Need second opinion on E/M level: MD saw pt for initial consultation. EHR template is completed with full HPI/ROS/PFSH and 8 bullets of exam. However, he states that prior to completing evaluation there was discussion of medications, our recommendations/protocols VS current regimen of meds VS other tx regimens tried previously, and patient stated she was satisfied w/current regimen and was not interested in changing. He also noted that "most of the information obtained in the remainder of this report is derived from intake form and initial interview with MA."
The Doctor assigned level 2 E/M. My supervisor is questioning that it is too low. I'm on the fence: The documentation will support level 3, but he clearly states the patient was not interested in the offered tx approach, thanked him for his time and left.
 
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If he did the work ...

But he did all the work of a level 3 ...

Ask him this ... what if the patient had agreed ... let's say it's a new Rx ... would he feel the EXACT SAME NOTE would equal a level 3?
Now what if the patient never fills the prescription?

The patient's decision to follow-through on the recommended course of action does not determine the level of the visit. The physician's documented work is what we look at to determine the level.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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