Wiki Determining level of service

[pscott]

In our office we have a question abot determining the level of service. I recently took
the E&M course, but cannot find this in any of the examples. If the history, examination, and Medical decision are all in a different column, which one do you choose? for example, if you have an established patient who has a Detailed History, an Expanded Problem Focused exam, and Straightforward medical complexity, which level do you choose. Also, we were told by an auditor that if a prescription is writted, that makes it a 99213. How do you document that?
Thanks in advance!

 

[mitchellde]

for an established patient it is the best 2 of three, so for you example, you can disgard the MDM and base the level on detailed hx and exp focused exam, since exam is the lowest of the 2 left you base the level on expanded focused exam, as long as the medical necessity is consistent with that level of service. A writtten prescription is not an automatic 99213 , a prescription is only risk which is one of the 3 elements of MDM.

 

[pscott]

Thanks!