# vaccine request/deferred exam



## MICHELLE1279 (Jul 2, 2008)

I'm not 100% sure I agree w/my physicians level 2 E/M for this visit, any suggestions?  HPI - pt is here requesting adacel vaccine.  To me that doesn't count as problem focused HPI, am I wrong?  PMH/SHX documented.  Review of syst/exam incl temp/pulse/bp and resp rate/weight.  Further exam declined.  Patient was not given the adacel vaccine as she is breastfeeding, and last tetnus date is unknown.  Could he bill a level 2 for this encounter, and what would the dx be?  She has no issues addressed.  She was directed to get her prev med records, and schedule a nurse visit when she is no longer breastfeeding.  Thanks for any insight.


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## tennislaurie (Jul 3, 2008)

What I don't understand is why patient was scheduled when provider could not administer the vaccine due to her breastfeeding.  I see no chief complaint or any indication that this visit was medically necessary. At most, it looks to me like all they did was take her vital signs. I would not be billing a level two visit.


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## dmaec (Jul 3, 2008)

For an established patient only 2 of the 3 elements of the components need to be met.  So if documentation supports a level 2 he can bill it.
HISTORY COMPONENT= PROBLEM FOCUSED
HPI PF -with question adacel vaccines. The doctor reviewed with the patient the Adacel Vaccine-the fact that she couldn't get it now and why and when to come back - reviewed with patient that last tet was unknown.
ROS EXP with 1 under constituional;
PFSH COMP -with two being documented; 

EXAM COMPONENT =NO EXAM;

MDM-STRAIGHT FORWARD

PF/no exam/Straight Forward = level 2


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