ARCPC9491
True Blue
I have read tons of the postings on here regarding E/M...one of the obvious things I see is regarding Medical Decision Making and the risk component.
Just because you have a "new problem" and a "prescription" doesn't necessarily mean the overrall Medical Decision Making is of Moderate....which as we know correlates to a level 4 (given the history, exam are sufficient for the type of E/M)
For example, I've seen a ton of notes where people are giving level 4's for pharyngitis or otitis media just because it's a new problem and they gave a prescription. Most providers would agree that for these problems, the Medical Decision Making is of Low Complexity. It is commonly routine to give prescriptions for these types of conditions.
Even though "the table and points system" gives you a Moderate Decision Making, doesn't mean it's a level 4. No tables or points can justify medical necessity - which of course is the number #1 key component of all.
So next time you see a patient for a minor condition that requires a prescription.....re-evaluate your decision to go with Moderate decision making.... I believe most people would agree you are overcoding.
Just because you have a "new problem" and a "prescription" doesn't necessarily mean the overrall Medical Decision Making is of Moderate....which as we know correlates to a level 4 (given the history, exam are sufficient for the type of E/M)
For example, I've seen a ton of notes where people are giving level 4's for pharyngitis or otitis media just because it's a new problem and they gave a prescription. Most providers would agree that for these problems, the Medical Decision Making is of Low Complexity. It is commonly routine to give prescriptions for these types of conditions.
Even though "the table and points system" gives you a Moderate Decision Making, doesn't mean it's a level 4. No tables or points can justify medical necessity - which of course is the number #1 key component of all.
So next time you see a patient for a minor condition that requires a prescription.....re-evaluate your decision to go with Moderate decision making.... I believe most people would agree you are overcoding.