sluke9
Guest
Pediatric practice....
Teenage patient is being seen for well visit. The patient is found to be obese so the dr orders labs & counsels the patient & parents in his A&P. Vital have his weight and BMI documented. I don't think this is enough to really warrant an additional E/M level.
Another scenario: patient being seen for well visit, HPI talks about weight issues & diet/exercise, vitals have weight & BMI, exam doesn't mention anything else, A&P has labs ordered, counseling.
My feeling is that weight is a normal thing discussed during a well visit. Ordering a lipid panel is out of the normal testing done for a teenage child but to me the documentation can't really support 2/3 components for additional level.
Thoughts???
Teenage patient is being seen for well visit. The patient is found to be obese so the dr orders labs & counsels the patient & parents in his A&P. Vital have his weight and BMI documented. I don't think this is enough to really warrant an additional E/M level.
Another scenario: patient being seen for well visit, HPI talks about weight issues & diet/exercise, vitals have weight & BMI, exam doesn't mention anything else, A&P has labs ordered, counseling.
My feeling is that weight is a normal thing discussed during a well visit. Ordering a lipid panel is out of the normal testing done for a teenage child but to me the documentation can't really support 2/3 components for additional level.
Thoughts???