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Great question. There are no documentation requirements for selecting your level. However, simply refilling a medication without it being "evaluated" in the encounter would not be appropriate. As you describe, there is some documentation that you evaluated the problem, and, while good practice to document your assessment/plan which could be as simple as "stable ADHD, refilling med" there is no requirement that you specifically document a plan. So if you evaluated 2 stable chronic problems and performed prescription drug management, that would be a new level 4 99204 based on problems and management.

Thank you! I appreciate it and am glad it is useful for you.

Thanks so much!

Much Appreciated!

You're welcome!

Thank you for catching this! I apologize for the error. I will fix this in a future update and put a note in the video explanation.

Hi. I’m assuming you are talking about example 2. All 3 problem, data, and risk are moderate. Moderate problem due to clinical presentation having systemic findings such as fever and decreased urination. A different provider may have deemed this a low complexity problem and there is subjectivity involved. It is the provider’s prerogative in making the selection for each individual case using the guidance provided by the guideline (I discuss this at the end of the example). Data is moderate because there is a UA, urine culture, and a parent providing history. Risk is moderate due to prescription drug management. So overall the level would be moderate (level 4) hope that helps. Thanks for watching. Try the calculator on my website and play around with changing things to see how it affects your final code.

Wow! Thanks for that. I feel blessed whenever I’m able to help someone. Good luck in your studies!!

Me too. But I’m having problem understanding the MDM part : (

You're welcome

@@dostrovsky1 question for the data table the problem is high and the data should be moderate as 2 tests are reviewed and 1 outside source and the risk was moderate should be a level 99222 correct. My coding team notes a hight level for the data but it notes 1 out of the 3 categories any combination of the 3.

Hi ​ ​ I’m not sure I understand your comment. I assume you are referring to the last example. Again to summarize…. A hospitalized patient responding to treatment would be a low for problem. Pulse ox, cbc,metabolic panel 3 points is moderate for data, and antibiotics, steroids, and breathing treatments carry moderate risk in my opinion. This yields level 1 problem, level 2 data, level 2 risk. 2/3 at or above 2 so overall level 2 with subsequent visit CPT 99232. Hope that makes sense.

@@dostrovsky1 thanks much

Glad it was helpful!

Thanks for watching!