New Patient Encounter

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Instructions:

• Review the SOAP note accessed through the link below. ; For purposes of the assignment, the patient is a ‘new patient’ in the practice.
  • New Patient SOAP Note. ;ATTACHED
    

Initial Post

Use your lecture materials to determine what CPT E&M Code to utilize for this ‘new patient’ encounter. ;ATTACHED)

You may choose to assign the code based on the anticipated/guestimate amount of time the provider would spend with the patient in the encounter or you may choose to utilize the Medical Decision Making (MDM) approach. ; If you choose the MDM include the following information in your discussion:

1. the level of history taking achieved – identify the history elements present
2. the type of exam performed – identify the number of systems and bulleted points in the note
3. the level of medical complexity encompassed – include # of points for a) diagnoses/management options, b) amount/complexity of data reviewed and c) level of risk for complications, morbidity, mortality