Wiki Level of Risk queston

[KaylaRieken]

If a patient has been taking a medication and they are still having problems and the doctor ups the dosage on the medication would that be considered moderate in the level of risk? Could I charge a 99214 for it if they hit all the other points in the encounter?

 

[thomas7331]

If a patient has been taking a medication and they are still having problems and the doctor ups the dosage on the medication would that be considered moderate in the level of risk? Could I charge a 99214 for it if they hit all the other points in the encounter?

Prescription drug management (assuming this is not an OTC medication) is identified as a marker for moderate risk level. But risk is only element of MDM - you would also need to consider your diagnosis and data points. From what you've said, you could probably consider this as a single established problem that is worsening, which would count for 2 data points, but that would only give you a low level of MDM unless there is something more in the documentation in the way of other problems, or data that is being reviewed and evaluated by the physician. But then, you could still meet the level of 99214 with your history and exam, if they qualify.