Medical necessity is the driving factor, but MDM is not what determines medical necessity. It can be a good indicator but it is not the end all be all.
I have no idea what happened in your case but I use this type of a visit as an example to my providers all the time. In fact I just had my daughter in for the same basic thing yesterday.
A detailed history is done along with a detailed exam. You have a new problem with no work up (3 pts), obviously no data pts, so it comes down to the table of risk to determine your MDM level. If they give a script at this point you are at moderate. If they don't you are most likely stuck at low (OTC) or even straight forward (rest).
So the only difference between an undeniable 4 and a 3 or even a 2 is where they fall on the table of risk. They are doing the same work in obtaining hx and doing exam. They have the same dx and work up pts. They have the same presenting problem. If the doctor had written a script you would not even be questioning the level, it would be a straight 4.
Unless this was a follow up visit, I say the 4 is correct.
Just my take on it,
Laura, CPC, CPMA, CEMC
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