Wiki Question regarding MDM

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cbooker

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Patient is being seen for acute sinusitis. Physician is billing a 99214. He has an expanded problem focused history, detailed exam and moderate complexity for his medical decision making. When auditing this I gave a "3" under number of diagnoses because this was a new problem to the doctor and under amount and/or complexity of data reviewed it came out to a "0" since nothing was ordered. Risk of complications came out to a moderate due to the fact patient was given a rx for an antibodic. Is this correct? This seems to be a high level for just sinusitis.
 
This is correct. You have to consider that anytime they give an Rx they are putting themselves at risk, whether the reason seems simple or not.

Laura, CPC, CEMC
 
Pt is coming with cough, nasal congestion & headache, Assessment plan : Acute Recurrent maxillary sinusitis with Rx given Amoxicillin can we consider in MDM problem point as Acute illness with systemic symptoms & Risk is moderate, please suggest E&M level ?
 
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