Wiki E/M Medical Decision Making

[caarchil@ncsu.edu]

Hello!

Could someone please tell me if a patient has a bilateral problem (ex. bilateral knee pain), would this be considered 1 or 2 problems when trying to determine the level of medical decision making. Does anyone know of any helpful resources? Thank you so much!

 

[thomas7331]

Hello!

Could someone please tell me if a patient has a bilateral problem (ex. bilateral knee pain), would this be considered 1 or 2 problems when trying to determine the level of medical decision making. Does anyone know of any helpful resources? Thank you so much!

It could be either 1 or 2 problems, depending on what is documented. For example, if these are injuries that need to be evaluated and treated separately, I would count them as two problems. But on the other hand, if the pain was due to arthritis and was treated with a single prescription of a pain medication, I would consider this one problem. Each E&M record really has to be considered on its own merits.

 

[caarchil@ncsu.edu]

Thank you so much for your response! I am new coder so any help is appreciated!