Coding Corner Question: November

What Level is the Medical Decision Making of this E/M Visit?

Assessment

1. Rheumatoid arthritis: worse on chronic medicine
2. Osteoporosis: stable on chronic medicine
3. Elevated blood pressure (BP): new problem

Treatment Plan

1. Start tumor necrosis factor inhibitor. Physician held a lengthy discussion with patient concerning risks and benefits. A skin test and chest X-ray were performed for tuberculosis screen. Labs were drawn for disease evaluation and medication monitoring. She is to continue other medicines. Risks and benefits were reviewed with patient.
2. Osteoporosis: Dual-energy X-ray absorptiometry due and ordered to reassess. Continue Fosamax, calcium, and vitamin D.
3. BP: patient to check at home and keep log.
4. Labs to check toxicity level of drugs. Complete blood count, comprehensive metabolic panel, erythrocyte sedimentation rate, C-reactive protein, and hepatitis panel were ordered due to disease and medicines.

How is this coded?

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