coding303
Networker
I am looking for a bit of information concerning E/M levels for an Urgent Care. Here is my visit:
The presenting problem itself would fall under the low risk category of presenting problems alone. Here is what I have in the documentation:
Comprehensive History and Exam
Complexity of MDM
Dx-
New Problem to Examiner, no workup planned- 3 points
Data-
lab tests ordered and performed, radiology ordered & performed - 2 points
Risk-
Rx medication dispensed- Moderate Level of Risk
My question is if it is appropriate to assign a 99204 for my new patient visit if prescription drug management is my only indicator of moderate risk management. I am unsure if this would fall into a 99203 or 99204. Any assistance appreciated.
The presenting problem itself would fall under the low risk category of presenting problems alone. Here is what I have in the documentation:
Comprehensive History and Exam
Complexity of MDM
Dx-
New Problem to Examiner, no workup planned- 3 points
Data-
lab tests ordered and performed, radiology ordered & performed - 2 points
Risk-
Rx medication dispensed- Moderate Level of Risk
My question is if it is appropriate to assign a 99204 for my new patient visit if prescription drug management is my only indicator of moderate risk management. I am unsure if this would fall into a 99203 or 99204. Any assistance appreciated.
