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.
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.