Interestingly enough, on E/M's University case of the week, Dr. Jensen has this same scenario. See below.
INTERVAL HISTORY: The patient is here to discuss risks and benefits of statin medication which was started last time for dyslipidemia with LDL of 160. Several friends have had adverse reactions to these agents and she wants to know if she really needs to continue this medication.
NAD, conversant; looks younger than stated age.
BP 124/72 HR 84 RR 18
EXT: No peripheral edema
Labs: LDL 92
1. Optimally controlled dyslipidemia
1. Continue PRAVASTATIN 10 mg PO QD.
2. RTC in six months with LFTs and lipid panel.
Time: I spent 16 minutes face-to-face with the patient, over half of which was devoted to counseling and/or coordination of care. We discussed the role of statin medications in primary prevention of cardiovascular events. All questions were answered to her satisfaction.
For MDM, here is what he did:
Here you get only one problem point for the established and stable problem of dyslipidemia.
Here you get one data point for ordering and/or reviewing labs.
This encounter qualifies as being of low risk based on the presence of one stable chronic illness.
One reader was wondering why the risk was low instead of moderate based on the RX. Dr. Jensen says that in order to qualify for moderate risk for RX management, you should be starting, stopping, or adjusting the medication.
I agree with Dr. Jensen on this. The "risk" is the "risk until the next encounter" if the medication has proven to work and control the issue from the initial encounter to present encounter, if nothing has changed in the patients condition to warrant a change in the med(s), the "moderate risk- RX management" should not be used.
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