Im doing an audit for a physician and I am having a hard time with the MDM.
CC: Pregnancy Verification; LMP 9/15/09 irr. cycles. Bled X 1-2 days in october with cramps.
ROS: 13 systems reviewed
EXAM: wt: 314ib. Ht:64.5in. BMI:53.1. Obese A/A female in no acute distress. Affect is normal and appropriate. Mucosa pink and moist. Chest is CTA. Heart RRR without murmers. Gait is WNL. Abd: Obese. soft. nontender. FH@153BPM. fundus-16w.
Ordered: an OB ultrasound.
my question is since the pt is obese and puts her at a higher risk does that make the visit a moderate risk level or since there isnt any complications noted is it a lower level MDM. another question i am having is pregnancy as a chief complaint. how can i use that as my chief complaint? any help will be greatly appreciated.
Ivonne
CC: Pregnancy Verification; LMP 9/15/09 irr. cycles. Bled X 1-2 days in october with cramps.
ROS: 13 systems reviewed
EXAM: wt: 314ib. Ht:64.5in. BMI:53.1. Obese A/A female in no acute distress. Affect is normal and appropriate. Mucosa pink and moist. Chest is CTA. Heart RRR without murmers. Gait is WNL. Abd: Obese. soft. nontender. FH@153BPM. fundus-16w.
Ordered: an OB ultrasound.
my question is since the pt is obese and puts her at a higher risk does that make the visit a moderate risk level or since there isnt any complications noted is it a lower level MDM. another question i am having is pregnancy as a chief complaint. how can i use that as my chief complaint? any help will be greatly appreciated.
Ivonne
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