Appropriate Billing Levels Essay

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Medical Billing/Coding Analysis for 3 patient visits:

Instructions: after reading the clinic notes for each of the 3 patient above, determine the level of billing based on the history, physical exam and complexity of medical decision making. You can highlight your choice in each category, but be sure to provide your rationale for your choice, based on the Medicare Evaluation Management guidelines (located in Module 4 documents). In the final row, select the overall level of billing for this visit, and provide your brief rationale for this level.

Example: Pt.#1 History: If I had highlighted "expanded problem focused," my rationale should include # elements addressed and # body organs/systems included to support the level I selected.

Patient 1: Stephens

Patient 2: Thomas

Patient 3: Evans

History Problem focused

Exp problem focused

Detailed Stephens

Comprehensive

Rationale: There was a detailed family and personal history provided as well as at least six different systems examined.

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Problem focused

Exp problem focused

Detailed

Comprehensive Thomas

Rationale: The patient and doctor discussed eight different areas of concern along with a limited family and personal history. Along with the eight areas, a discussion was launched with the patient that included a number of areas of concern that had not been addressed within the last 12 months (and in fact it had been over 2 years since the patient had been examined).

Problem focused

Exp problem focused Evans

Detailed

Comprehensive

Rationale: The doctor spoke to the patient about two separate issues, including the diagnosed poison ivy and her recent bout with UTI but very little personal or….....

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