vaccine request/deferred exam

MICHELLE1279

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I'm not 100% sure I agree w/my physicians level 2 E/M for this visit, any suggestions? HPI - pt is here requesting adacel vaccine. To me that doesn't count as problem focused HPI, am I wrong? PMH/SHX documented. Review of syst/exam incl temp/pulse/bp and resp rate/weight. Further exam declined. Patient was not given the adacel vaccine as she is breastfeeding, and last tetnus date is unknown. Could he bill a level 2 for this encounter, and what would the dx be? She has no issues addressed. She was directed to get her prev med records, and schedule a nurse visit when she is no longer breastfeeding. Thanks for any insight.
 

tennislaurie

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What I don't understand is why patient was scheduled when provider could not administer the vaccine due to her breastfeeding. I see no chief complaint or any indication that this visit was medically necessary. At most, it looks to me like all they did was take her vital signs. I would not be billing a level two visit.
 

dmaec

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For an established patient only 2 of the 3 elements of the components need to be met. So if documentation supports a level 2 he can bill it.
HISTORY COMPONENT= PROBLEM FOCUSED
HPI PF -with question adacel vaccines. The doctor reviewed with the patient the Adacel Vaccine-the fact that she couldn't get it now and why and when to come back - reviewed with patient that last tet was unknown.
ROS EXP with 1 under constituional;
PFSH COMP -with two being documented;

EXAM COMPONENT =NO EXAM;

MDM-STRAIGHT FORWARD

PF/no exam/Straight Forward = level 2
 
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