If an established pt is seen and a new med is introduced, all aspects must be considered. Is the med Ibuprofen? Is that, really, a moderate risk? Is the med Coumadin? How does that risk compare to Ibuprofen? In any case, for a follow up, only 2 of the 3 criteria must be met or exceeded to choose a code (i.e. history, exam, MDM). If an established pt is there for a refill of the same dose, it seems to me the risk of complications or morbidity is low. A change in dose, however is different. But again, what is the med? I hope this helps. Isn't this business a blast?
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