PLEASE HELP, 1995 guidelines

mpl5btx

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I am having trouble choosing the correct E/M level using 95 guidelines. For example a lot of the notes I see don't have any HPI, would this automatically make the history problem focused even if there are ROS and PFSH? Also what if the history is a 2, exam a 4, and MDM is a 3, what level do I choose?
 

jmcpolin

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You wouldn't be able to bill a new patient if there was no HPi but if it is a follow up you only need 2 of the 3 History physical exam and medical decision making. For what you have listed you could code a level 2
 

mpl5btx

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Ok, that's what I was thinking I should go with the lowest level for these cases when it's a follow up

Thank you
 
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