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Wiki Medication mgmt visit

Lbibian

Contributor
Messages
12
Location
Granada Hills, CA
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Would a medication management visit with these notes justify a level 5? I don't believe so, but one of my providers is challenging me

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Would need the rest of the note to even code an E/M, we can't decide based only on the A/P. There is no chief complaint or reason for visit here.
Just looking at that, it's not a level 5 unless they correctly documented and coded by time with a # of minutes to support a 5. Otherwise, this is probably a 4. Looks like possibly 1 chronic, exacerbated and prescription drug mgmt.
 
I would ask the provider what the reasoning is and why they feel it's a level 5. This is not a 5 based on the documentation. Did this visit take 40 or more minutes and they forgot to document the visit based on time? That would be the only way.
This is Mod/None/Mod. 4.
 
I would ask the provider what the reasoning is and why they feel it's a level 5. This is not a 5 based on the documentation. Did this visit take 40 or more minutes and they forgot to document the visit based on time? That would be the only way.
This is Mod/None/Mod. 4.
Thank you for the advice
 
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