Wiki Determining the level of service

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avogel1

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Good morning. I have an established patient whose history is an EPF, detailed examination and straightforward decision making. We have to have 2 out of the three, but when this is not met how do I determine the level of service? Thanks!
 
Two out of three for an established patient for this a level 3. For established you can throw out the lowest, then of the two criteria left the lowest of the two. EPF history is a level 99213, if this were a new patient it would be a 99202
 
Actually the diagnosis is the driving factor. If the visit level does not correspond with the diagnosis there could be an issue.
 
The patient has controlled hypertension as stated in the HPI. They had a complete physical exam. There was no lab work ordered.
 
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