REVELLE
New
I need some help on a level of service for an ER patient. All the ER docs do a wonderful job at documenting to the highest Level of service but I was taught you go by the complexity. So on the patient all the bullets are met for a level 4 e/m for the physcian. the DX 462 was used and the general comments for the patient were:
General comments: The patient has sore throat, congestion and body aches consistent with a viral URI. He has mild swelling of his left periauricular and cervical chain lymph nodes. He has no tonsillar swelling or deviation. He has mild erythema, but his strep and influenza testing are negative. This may represent mononucleosis and we discussed supportive therapy for this. He will use medications for symptom control and at this point there is no indication for antibiotic therapy.
What level would you give the doc? Thank you
General comments: The patient has sore throat, congestion and body aches consistent with a viral URI. He has mild swelling of his left periauricular and cervical chain lymph nodes. He has no tonsillar swelling or deviation. He has mild erythema, but his strep and influenza testing are negative. This may represent mononucleosis and we discussed supportive therapy for this. He will use medications for symptom control and at this point there is no indication for antibiotic therapy.
What level would you give the doc? Thank you