That said, be careful not to bump a whole E/M level up based solely on the fact that an Rx was mentioned; some situations don't necessarily warrant a higher level of E/M simply because a prescription was given, and this area of E/M has a tendency to produce a falsely-high result. Use your judgement in assigning the overall level, and only assign the level that is supported by medical necessity, in the event that the documentation adds up to a high level code every time. Use the clinical examples in Appendix C of the CPT book to guide you. Hope that helps!
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