Question self-limited or minor or more?

wynonna

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Hello and looking for your help:
If a provider sees a patient with what is considered more than a self-limited or minor problem, does that raise the overall level to a level 3 for low risk in Risk column? ( In the case where there is no independent historian, no Tests, No OTC, nor surgery nor PT/OT, nor IV?)

I'm looking for a general, practical way to differentiate a level 2 from a level 3.

thank you
 

csperoni

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The problem and the risk are 2 different elements. You could certainly have a chronic stable problem with minimal risk.
For leveling visits, you must level each individual visit based on documentation. There is no simple answer of something like HTN = level 2, or level 3, or level 4. Two patients with the same diagnosis could have very different treatment plans based on severity, co-morbidities, etc.
 
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