What Level is the Medical Decision Making of this E/M Visit?
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Explore This IssueNovember 2012
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- Rheumatoid arthritis: worse on chronic medicine
- Osteoporosis: stable on chronic medicine
- Elevated blood pressure (BP): new problem
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- 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.
- Osteoporosis: Dual-energy X-ray absorptiometry due and ordered to reassess. Continue Fosamax, calcium, and vitamin D.
- BP: patient to check at home and keep log.
- 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?