Wiki What level of service?

[blaymon]

A patient is diagnosed with uvulitis and has a fever of 100.4F and a heart rate of 76bpm. Her voice is hoarse. POCT strep test is negative. A dexamethasone injection is given in clinic and the patient monitored for 30 minutes with improvement in symptoms. What level of service would this encounter be?

 

[twizzle]

What level do you think it is and why?

 

[blaymon]

This is a disagreement between a physician and myself. I told him this would be a level 3 visit. He thinks it is a level 4 visit due to fever.

 

[natashalage]

Hi, I am not an expert but my rational as such: level 3 because Problems- Low ( acute uncomplicated), Data-1, Risk- drug management- moderate= Low-99213-25+injection CPT. You can provide MD the descriptions of each component of E/M and he will see the difference between level 3 and 4. ( As for me, I am always eager to learn if I am wrong.)

 

[twizzle]

This is a disagreement between a physician and myself. I told him this would be a level 3 visit. He thinks it is a level 4 visit due to fever.

I suspect your provider thinks that fever qualifies as an acute illness (uvulitis) with systemic symptoms but fever doesn't automatically qualify as a systemic symptom. It would need to affect the entire body to qualify as systemic.

I agree with a level 3 based on the other elements of MDM - straightforward for data and moderate for risk.

 

[blaymon]

My thoughts exactly. I appreciate your comments!