Help with E/M level

medcode12

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Chief Complaint - ear pain & cold

Physical exam of HEENT, chest, abdominal, skin & neuro.

Diagnosis made of OM and URI and Amoxicillin prescribed.

No history was documented so I'm focusing just on the exam and decision making.


Would the physical exam be considered comprehensive?
Also, would the level of decision making be of moderate or low complexity?


Thanks in advance for your help!
 

KHaley321

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Pittsburgh, PA
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Level 4?

Well first, I hope this is an established patient since you are only focusing on 2 out of the 3 key components, which I'm sure that it is.

And as for the MDM, it would be moderate for the level of risk because it automatically reaches that level for a prescribed med, but you didn't give enough information to decide the other 2 areas (Number of diagnoses or treatment options & Amount and/or complexity of data reviewed) in the MDM section to give the complete level of complexity.

For the Exam, I would say that it's Detailed because I checked off 5 things in one section, since from what I understand that you are not allowed to count both sections of the exam all together. It has to be one or the other (the body areas or the organ systems).

So overall, I would say that it should be a level 4 if it's an establshed patient and if you wind up getting a total moderate complexity for the MDM if other the other missing information is available.

I hope that helps somewhat...:)
 

ARCPC9491

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Chief Complaint - ear pain & cold

Physical exam of HEENT, chest, abdominal, skin & neuro.

Diagnosis made of OM and URI and Amoxicillin prescribed.

No history was documented so I'm focusing just on the exam and decision making.


Would the physical exam be considered comprehensive?
Also, would the level of decision making be of moderate or low complexity?


Thanks in advance for your help!
I would give the exam Expanded Problem Focused based on 1995 guidelines. I'm not going to assume it's higher because you haven't provided any detailed information. I don't know what your physician specifically documented, so I can't use 1997 guidelines.

As for MDM, I say 2 Self Limited Issues and Moderate Risk. You need 2/3 so your overrall MDM is of Low Complexity.

=99213
 
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