Wiki Determining Medical Decision Making

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lnaschke

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For the Medical Decision Making how would the following be coded for a new patient?

Physician ordered/reviewed Influenza Types A&B lab done inhouse

Assessment: Like URI, no sore throat and flu negative. Continue Motrin as needed and prm OTC med. Return to clinic if new/worsening

DX: 079.99, 462

Based on my review:

Number of DX : Moderate
Risk of Comorbitiy: Low
Amount of Data Reviewed: Minimal

Level of MDM: Low
HPI: EPF
Exam: Complex

Level of service: 99202

Does this look correct?

I
 
Yeah, unfortunately since the History in your example is Expanded Problem Focused the best you can get out of this is a 99202.

If they had a Detailed Hx and Exam, and Low MDM (which I agree you have) that's sufficient for a 99203. Looks like the history was underdocumented.
 
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