Is this the ENTIRE note?
Is this the ENTIRE note? If so, there is not enough documentation for ANY level of new patient visit.
If it's a new patient, then the problem is - by MOST payer's definition - a new problem (NOTE: Some payers say that the problem has to be new to the PATIENT, so even if you've never seen the patient, if someone else has treated the patient for the problem, it's considered an established problem - YIKES).
You are ordering additional labs, so it seems that perhaps this is a new problem w/ additional work-up = 4 pt
You get 1 data pt for ordering the labs
Not knowing what the complaint is (I'm guessing something related to possible anemia, but I'm not sure) the only level of risk I can come up with is based on the treatment option, which is ordering lab tests and a f/u visit - Minimal Risk
If you post the entire note, my answers might be different.
Hope that helps.
F Tessa Bartels, CPC, CEMC