You have to use common sense. The MDM determines the level. If someone has strep and they give the patient a RX for ABX, it is low complexity. Just because the "puzzle" comes out a level 99284, the complexity of the visit would still be low. 99282
Take a look at the ED codes in the CPT book.
99281 - problems are self-limited or minor
99282 - problems are low to moderate severity
99283 - problems are moderate severity
99284 - problems are high severity and require urgent evaluation by the physician but do not pose an immediate significant threat to life or physiologic function.
99285 - problems are of high severity and pose an immediate significant threat to life or physiologic function.
So does a sore throat, even though they got a Rx for Abx a "high severity" problem.
For example: You could have a 40 year old that comes in with chest pain that turns out to be a MI. You could also have a 60 year old that comes in with chest pain and turns out to be too many chilli dogs. Which means your documentation for both cases would be a Comprehensive History and Comprehensive Exam. The MDM will decide whether it is a MI for the 40 year old and probably an admission or maybe just Observation for a rule/out MI. Where as the 60 year old could go home after getting some maloxx and a Rx for Previcid.
The bottom line the MDM drives the visit. Hope this helps.
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