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Thread: Dealing with Peds E/M

  1. #1
    Join Date
    Apr 2007

    Default Dealing with Peds E/M

    AAPC: Back to School
    Seeking guidance, Does this sound right. Auditing a physicians notes. The note reads to me, a 12yr old with new prob. Pharyngitis. No HPI, but we have Exam on TM. Documented with some detail. And lungs, also documented with some detail. With a prescription of Keflex. Does this qualify for a level four. Keep in mind this is an Establish patient.

    So we got: Establish Patient
    2 detailed body areas examined
    New Prob
    Prescription Drug given.

    Using the 1995 guidelines, do we come up with a level four.
    Need input.


  2. #2
    Join Date
    Apr 2007


    in the Er as long as you have an HPI Ros and Exam your covered but the risk is low here so a level 3 for giving the persription or if he did x-ray but if his temp was above 104 then you can give a level 4 or IV anything was givin

  3. #3
    Join Date
    Apr 2007
    Watertown, NY


    from what you stated i came out with a level 3 too.
    mdm is level 4 but exam is level 3 history was a level 2. so to meet 2/3 it would be a 3
    good luck.

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