Yes - this would be a moderate level of MDM. I do coding for an Urgent Care and 99% of our patients are there for a new problem - which we always get a to the 3 for problems - sometimes 4 if we send them out for testing. An ear infection usually gets an antibiotic, which gives the risk of Moderate. Those two areas together get you a Moderate MDM! As long as the doctor documents a Detailed History and/or Exam (depending on if patient is new or established) you would definitely be within a 99214 without an issue!
As far as worrying about RAC - our Medicare carrier - Highmark - stated at a seminar on E/M coding that anytime the doc mentions an RX -new, changed, refilled or continue - the risk is automatically Moderate. That is how we base our coding!
Jodi Dibble, CPC
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