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E & M question

  1. Default E & M question
    Exam Training Packages
    Hi! I have a couple of questions that I would love some other opinions on

    If the doctors states under Medications : Too numerous to list, patient is on over 20 medications. Could you use this statement to quality for Moderate Decision Making?

    We use mostly 95 guidelines and they seem to always give me Neck - No nodes are palpable & trachea is midline. I have told them lymph node etc & that Neck is not a Organ system, but they still say nodes not palpable. Would you give credit for lymphatic system on this...?

    Thank you !

  2. #2
    Ellenville, New York
    Default Opinion
    I would count the nodes not palatable as lymphatic as that would be part of his objective examination and they are part of the lymphatic system.

    The listing of the 20 meds - that sounds more like part of the PFSH instead of the MDM. However, if the doctor documented a change in dosage, etc of any of these 20 meds, then I would use it for the moderate risk.


    Director, Health Information Management
    HealthAlliance of the Hudson Valley
    Kingston, NY

    2016 Secretary
    Ellenville, NY Local Chapter

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