These are my thoughts and hoping the veterans will comment. I've worked it from the MDM backwards and have come up with a level 4 for this established patient.. Briefly you have MODERATE MDM due to the presenting problems of HA and HTN along with medication management. Not sure if the EXAM would be PF or EXP because I only count 5 items. Are you using 95 or 97 guidelines? (Doesn't really matter since the other two components will substantiate the level.) HPI contains the following elements: location, quality, severity and modifying factors which qualifies for an extended HPI + 2 bullets for ROS and PMH = DETAILED. Since you've met two out of 3 required components for an established patient, I would assign Level Four. Again, hoping others with credentials in this field will comment (and correct my thinking) as I have a keen interest in this area. ---Suzanne E. Byrum, CPC
- ICD-10 Trainings
- Comprehensive Courses
- CPC (Certified Professional Coder)
- COC (Certified Outpatient Coder)
- CIC (Certified Inpatient Coder) NEW!
- CRC (Certified Risk Adjustment Coder) NEW!
- CPB (Certified Professional Biller)
- CPMA (Certified Professional Medical Auditor)
- CDEO (Certified Documentation Expert – Outpatient) NEW!
- CPPM (Certified Physician Practice Manager)
- CPCO (Certified Professional Compliance Officer)
- VIEW ALL CERTIFICATIONS
Coding / Billing Solutions
- Audit / Compliance Solutions
Job Experience / Apprentice Removal
News / Discussion
- Other Resources
- Book Store
- Log In / Join