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.