Wiki E & M Dillema

jreisert

Networker
Local Chapter Officer
Messages
27
Location
Pinebush, NY
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Were having a big issue in our coding regarding e&M levels for the providers please help the provider wants level 5 for this o/v. Pt came in for f/u of chest pain he was seen in the ER. He stayed in the hospital for 2 days echo was done, stress test and everything was normal. ROS was done 3 GI,Genitourinary and Musculoskeletal. PE was done vitals, neck,respiratory,cardio ang abdomen both ROS and PE are all normal. Provider review the results from the hospital and mention that the pt was high risk dyslipidemia and obesity. PFT was abnormal. Plan: provider started the pt on Spiriva, instrusted to quit smoking. started on Singulair and prevacid. order sonogram of bladder to rule out gallbladder disease. GI consult to make sure it is not hep c since pt has history of hep c. return sooner if there is a problem. Please tell me if this is warranted to level 5. i will really appreciate any help. thank you.
 
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