DesiraeC_44688
New member
I need help, say a patient comes to the ER and is diagnosed with Otitis Media. The HPI and exam are both detailed. The medical decsion making is the part I get stuck on, the patient received an antibiotic prescription, was told to follow up with family Dr. in 5 days, the Dr. noted that he reviewed and agreed with the history from the nurses note.
Number of dianosis/treatment options would be moderate, because it's ER so it's considered a new problem with no additional workup. 3 points - Moderate complexity
Data would be straightforward with 1 point, Dr. reviewed nurses notes.
Risk would be moderate because a prescription was given.
Would the MDM really be a level 4 - moderate complexity? With what I mentioned above, I calculate the entire visit to be a level 4, that just seems high for the diagnosis. Am I doing something wrong?
I find I'm always second guessing myself with E/M coding. Any advice is greatly appreciated.
Number of dianosis/treatment options would be moderate, because it's ER so it's considered a new problem with no additional workup. 3 points - Moderate complexity
Data would be straightforward with 1 point, Dr. reviewed nurses notes.
Risk would be moderate because a prescription was given.
Would the MDM really be a level 4 - moderate complexity? With what I mentioned above, I calculate the entire visit to be a level 4, that just seems high for the diagnosis. Am I doing something wrong?
I find I'm always second guessing myself with E/M coding. Any advice is greatly appreciated.
