Determine the complexity of medical decision

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Reference no: EM133690202

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Determine the level of service: Determine the extent of history obtained Determine the extent of the examination performed Determine the complexity of medical decision-making If necessary, compare the medical documentation example Determine any procedure(s) performed. If necessary, compare the medical documentation against examples in the Appendix and Tabular List. SCENARIO: Thomas, Ken (10/25/1970) Age 51 MRN: 12226013 Primary Insurance: Blue Cross Blue Shield Primary Provider: Jean Burke, NP PROBLEM LIST: Hypercholesterolemia Essential hypertension Ischemic heart disease, chronic PROGRESS NOTE: Ken H. Thomas (DOB 10/25/1970) Age 51 VISIT 1: XX/XX/20XX Ken, an established patient, was seen today for an Annual Physical. The office visit involved a comprehensive history and examination. A visual acuity test was performed. He will return in 1-wk for fasting labs, order entered.

Reference no: EM133690202

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