1. Neck;supple,lymhphadenopathy (HOW MANY BULLETS?)
1 under MS for neck supple. With the lymph piece you have to check at least 2 areas to get any credit at all so they need to be more specific. Like neck and axilla.
2.Neuro;gait normal,tone and reflexes, alert-oriented x3 (HOW MANY BULLETS?) 2, gait is 1 under MS and A&Ox3 is 1 under psych. tone and reflexes is not specific enough for me to give credit.
2.If the final DX. is Bronchitis but the Exam is normal but in the Ros is positive, to I have to query the physician? Are your providers using EMR that is automatically throwing the exam in and they have to manually change it?
3.For Est.Visits the HPI is EPF and sometimes PF because there's always no ROS but the exam is always DETAILED and the MDM is always moderate (especially that our establishment is treating mostly HIV patients) can I consider always the EXAM AND MDM if the elements in the HPI is insufficient for a LEVEL 4.(2 OUT OF 3 COMPONENTS)
Again, I would like to know about the EMR possibility for this question as well. Usually the exam is the part we drop for leveling on established patients. There is nothing wrong with using exam and MDM but I just wonder if it is actually being done and not just copying over. Also with your MDM, I am going to assume you have more than just one issue going on because HIV alone is not going to get you moderate everytime. Once it is established/stable it is only 1 point.
Laura, CPC, CPMA, CEMC
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