I am completely confused as to how to determine an E/M level when a physician simply states "Patient is here for a follow up of medications visit. There is nothing in the notes stating that the medication that they are there to follow up on has anything to do with the systems that were reviewed or the physical exam. Also there is no DX to go along with the reason he gave the medication in the first place. I can't even get an HPI out of this record. When/how can i determine a level for a Medication Visit? Especially when there's no mention of altering the dosage that they are on.