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Wiki E/M Medical Decision Making

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caarchil@ncsu.edu

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Hello!

Could someone please tell me if a patient has a bilateral problem (ex. bilateral knee pain), would this be considered 1 or 2 problems when trying to determine the level of medical decision making. Does anyone know of any helpful resources? Thank you so much!
 
caarchil@ncsu.edu said:
Hello!

Could someone please tell me if a patient has a bilateral problem (ex. bilateral knee pain), would this be considered 1 or 2 problems when trying to determine the level of medical decision making. Does anyone know of any helpful resources? Thank you so much!
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It could be either 1 or 2 problems, depending on what is documented. For example, if these are injuries that need to be evaluated and treated separately, I would count them as two problems. But on the other hand, if the pain was due to arthritis and was treated with a single prescription of a pain medication, I would consider this one problem. Each E&M record really has to be considered on its own merits.
 
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