Tricky. If it were me I might ask if the provider meant to bill an office visit at all. If so, sounds like the documentation is lacking and wouldn't necessarily support the 5 even though the scenario probably does. I guess you could call it chronic with severe/life threatening and decision for hospitalization = high. Tough w/o seeing a note.Yes it was a chronic illness with severe exacerbation. From what the documentation says, the provider just called 911 and the patient was transported to the hospital in an ambulance. There is nothing about talking to anyone at the hospital and our clinic is not connected to the hospital in any way. The provider attempted to treat the illness by giving the patient food to bring his blood sugar up but it didn't work.
We would count this as a five on the MDM table. You hit the severe exacerbation on the diagnosis line and the decision regarding hospitalization. He clearly has decided the patient needs to be hospitlaized.Yes it was a chronic illness with severe exacerbation. From what the documentation says, the provider just called 911 and the patient was transported to the hospital in an ambulance. There is nothing about talking to anyone at the hospital and our clinic is not connected to the hospital in any way. The provider attempted to treat the illness by giving the patient food to bring his blood sugar up but it didn't work.