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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...
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 family history.
Physical Exam
Problem focused
Exp problem focused
Detailed
Comprehensive Stephens
Rationale: At least ten different areas were examined and discussed with the patient. Family and…
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