Wiki Level 3 or 4?

[Bernadette10]

Level 3 or 4? This is a followup clinic visit after hospitalization as an inpatient. For this statement of tests reviewed, can a moderate level be given? The note doesn't say how many test results were reviewed, but the record shows that multiple labs were done during the hospital stay by a different provider/specialty, so at least 3 would have been reviewed which would qualify for moderate. Or does the note need to say which particular tests were reviewed? Also would the risk be low or moderate? I was thinking low risk since the patient was only referred to another provider for medical marijuana, or would it be moderate since this would be a prescription even though the current provider isn't giving it? I was leaning toward level 4.

The following elements were performed or reviewed with patient:
Medications on D/C reviewed with patient/reconciled and updated in EHR
Diagnostic tests reviewed/disposition
Disease/illness education
Establishment or re-establishment of referral orders for community resources
Discussion with other health care providers
Assessment and support of treatment regimen adherence
Additional appointments coordinated

Patient comes in for followup after hospital admission. He was admitted for intractable nausea and vomiting which have resolved. He has neuropathy and chronic pain. He takes Gabapentin for pain but, they make him feel drunk. He would like medical marijuana as this improves his symptoms. This is the reason for his visit today. I have discussed with him that we do not do that here but have given him the name of 2 physicians in town that do.

PE:
General: . appears stated age, NAD
Cardio: RRR, S1,S2 present, no m/r/g's
Resp: CTA
Abdomen: soft, NT, BS present
Extrem: No edema noted to LE

Assessment and Plan:
Followup of nausea and vomiting, resolved.
Neuropathy.
Chronic pain.
Referred to X to discuss medical marijuana.

 

[csperoni]

If there's no mention of what the tests were or what the results were, then I would not count that. Additionally, if this clinician, or another of the same specialty in the same group was seeing this patient during the hospitalization, you would have received the review credit during the inpatient visits and could not count them again.
They also note "discussion with other healthcare providers", but again do not describe at all who/when/what was discussed.
Regarding risk, the reason rx is level 4 is because the clinician is evaluating a particular medication, dosage, interactions, side effects, etc. In this case, the clinician is simply saying "I don't prescribe that, here are some doctors that do."
I code this level 3 as documented.
I would also use it as an education tool for my providers. If there were multiple tests reviewed and/or discussion with another healthcare provider, improved documentation could result in an increased E/M level. I always advise my providers that I am trying to get them credit for all the work they do. But the work must be on the page for me to credit it.

 

[Bernadette10]

Thank you!

 

[OpenClaims]

I agree with the above comment that a level 3 would be appropriate here.

Level 3 or 4? This is a followup clinic visit after hospitalization as an inpatient. For this statement of tests reviewed, can a moderate level be given? The note doesn't say how many test results were reviewed, but the record shows that multiple labs were done during the hospital stay by a different provider/specialty, so at least 3 would have been reviewed which would qualify for moderate. Or does the note need to say which particular tests were reviewed? Also would the risk be low or moderate? I was thinking low risk since the patient was only referred to another provider for medical marijuana, or would it be moderate since this would be a prescription even though the current provider isn't giving it? I was leaning toward level 4.

The following elements were performed or reviewed with patient:
Medications on D/C reviewed with patient/reconciled and updated in EHR
Diagnostic tests reviewed/disposition
Disease/illness education
Establishment or re-establishment of referral orders for community resources
Discussion with other health care providers
Assessment and support of treatment regimen adherence
Additional appointments coordinated

Patient comes in for followup after hospital admission. He was admitted for intractable nausea and vomiting which have resolved. He has neuropathy and chronic pain. He takes Gabapentin for pain but, they make him feel drunk. He would like medical marijuana as this improves his symptoms. This is the reason for his visit today. I have discussed with him that we do not do that here but have given him the name of 2 physicians in town that do.

PE:
General: . appears stated age, NAD
Cardio: RRR, S1,S2 present, no m/r/g's
Resp: CTA
Abdomen: soft, NT, BS present
Extrem: No edema noted to LE

Assessment and Plan:
Followup of nausea and vomiting, resolved.
Neuropathy.
Chronic pain.
Referred to X to discuss medical marijuana.