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E&M Level

J

Janele.Charles

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Location
Queens Village, NY
can someone help me. i am a new coder and seeking a little assisting with the level of service for a patient that is symptomatic patient and the provider is testing the patient for covid. would this be a level 3?
 
The level of outpatient E/M service is determined by either MDM or time. You have not provided enough information about either to level the service.
MDM requires meeting/exceeding 2 of 3 elements of problem, data, and risk.
"Symptomatic" does not provide enough information to determine if it's an acute uncomplicated illness, an acute illness with systemic symptoms or even an acute illness that poses a threat to life or bodily function. An occasional cough is a symptom. So would be a fever of 102. So would difficulty breathing and pulse ox of 85. It's about the severity.
Data: You only have 1 data point for covid test, so that is minimal/none (level 2 data) unless there was an independent historian, or provider discussed patient with external provider.
Risk: Without knowing the treatment, this is impossible to determine. Did the provider recommend OTC meds? Prescription meds? Advise to go to the ER for immediate oxygen?
 
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