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Case of the Week
Medication Management & Samples
You see an established office patient with stable HTN and dyslipidemia.
- Assessment & Plan: No changes in medications. You schedule a follow-up appointment for four months with a lipid panel and a BMP.
- Complication: The patient informs you that her local pharmacy has closed due to increased retail theft.
- Intervention: You give her samples of her ARB to tide her over until she finds a new pharmacy.
What is the correct level of care?
Click to Reveal the Answer & Analysis
The Correct, Audit-Proof Code Is:
99214
Coding by MDM yields a Moderate complexity score. For an established patient, this corresponds to code 99214.
See How E/M-Code-Sense AI Solved This Case
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Step 1: Feed the AI
-
ASelect Encounter: Establish Office Patient
-
BEnter Note: Paste the raw clinical text.
-
CClick Analyze: Let the engine do the work.
Step 2: Get Instant Results
- ✓ Result is 99214 Level of Care
- ✓ No Audit Risk Flags detected
- ✓ Documentation Improvement (CDI) section guides your charting
- ✓ 1-click EHR Coding Rationale generation
- ✓ Fully transparent MDM Detailed Breakdown
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Detailed Manual Analysis
Because total time was not explicitly documented in the note, we must rely entirely on Medical Decision Making (MDM) to determine the correct level of care.
Time-Based Result: N/A
Time was not documented. Without a documented time statement, time-based coding cannot be used.
MDM-Based Result: 99214
The overall MDM complexity was determined to be Moderate. For an established patient, Moderate MDM points clearly to the 99214 level of care.
MDM Deep Dive: The "2 out of 3" Rule
You only need two of the three components to meet a given level. Here, Problems and Risk hit Moderate, carrying the entire score.
Problems Addressed: Moderate
The patient has two stable chronic illnesses (HTN and dyslipidemia), which fulfills the requirement for a Moderate problem complexity.
Data Reviewed: Low
You ordered 2 unique tests (Lipid Panel and BMP). Ordering exactly two tests/documents meets the requirement for Low data complexity.
Risk of Complications: Moderate
Providing samples of a prescription medication (ARB) constitutes "Prescription Drug Management," which is universally recognized as a Moderate level of risk.
The "2 out of 3" Rule Confirms Moderate MDM
Even with a Low Data component, having two components at the "Moderate" level secures the overall MDM score.
Data
LOW
Problems
MODERATE
(Middle Value)
Risk
MODERATE
The middle value is Moderate, which becomes the final MDM level.
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