Wiki What level would you give this scenario?

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carlystur

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A new patient comes to our neuro office with a newly diagnosed brain mass, but asymptomatic at the encounter. The provider only orders an MRI that's with and without contrast that we are not billing for otherwise. The provider wants to bill all new patients as level 4, but I don't see anything else in the assessment or plan to suggest that it should be that high. My thought is this is only a level 2 due to just the one MRI ordered. Would the "with and without contrast" part affect the data?
 
I am coming up with a level 3 , undiagnosed new problem, 1 data, low ( low risk of morbidity from additional testing) = 99213
Even more on level 3/ 4 , if there were external records reviewed and identified as such .
 
I'm with @lcolborn. With the information provided, level 3.
Problem = moderate (level 4) for undiagnosed new problem.
Data = minimal (level 2) for 1 ordered test. IF previous records were reviewed, could be higher.
Risk = low (level 3) for imaging study with contrast.
 
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