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Melonyr

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:confused:I have a physician documenting a detailed history and exam, but the MDM is of low complexity. The patient has a lumbar sprain and the physician is continuing the same meds and having patient return in one month.

Would you give this a level four for an established patient or a level three?

The HPI was brief, but with an extended ros and 1 history area, that's where the detailed history came from. I am just leary of coding as a level four as I don't see the medical necessity for a detailed exam when the patient essentially came in for a medication refill.
 
It sounds to me like a level 3. If the HPI is brief and the MDM is low, the exam could be comprehensive, and I would still say it is a level 3.
 
level

Please someone correct me if I am wrong, but if the HPI is brief, the highest level you can get for history would be a EPF, since you have to have 3 of 3 on history to qualify.
 
cheermom68, you are correct. History is 3 of 3, so a brief HPI limits you to no higher than and EPF history level.

Laura, CPC, CEMC
 
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