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daniel

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Seeking guidance, Does this sound right. Auditing a physicians notes. The note reads to me, a 12yr old with new prob. Pharyngitis. No HPI, but we have Exam on TM. Documented with some detail. And lungs, also documented with some detail. With a prescription of Keflex. Does this qualify for a level four. Keep in mind this is an Establish patient.

So we got: Establish Patient
2 detailed body areas examined
New Prob
Prescription Drug given.

Using the 1995 guidelines, do we come up with a level four.
Need input.

Daniel
CPC
 
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Medical Necessity rules

I would not call pharyngitis is "new problem" so much as I'd term is "one self-limited or minor problem." So, despite the Rx, I would classify this as at best a 99213 visit.
Tessa
 

rthames052006

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I would not call pharyngitis is "new problem" so much as I'd term is "one self-limited or minor problem." So, despite the Rx, I would classify this as at best a 99213 visit.
Tessa
I too agree with Tessa, I think this is one of those scenerios where Medical necessity could come into play....

I'd only give this a level 3.
 
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