Wiki Determining E/M Level

[wverret]

Good afternoon,
I have a provider record that indicates the patient is a new patient here for follow up care for a surgical procedure. In reviewing the documentation, the provider indicates that the individual needs to have a dtap. would you give this provider a point for ordering something from the medicine section?

Thanks
Willie

 

[pclaybaugh]

Is the provider documenting the vaccination as given in the clinic? Then get the administration and the HCPCS code for the vaccine. I would not give a data point for recommending that the vaccination be given.