Unit 2 discussion

Review the SOAP note accessed through the link below.  For purposes of the assignment, the patient is a ‘new patient’ in the practice.

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  • New Patient SOAP Note (see additional material section for soap note)

Initial Post

Use your lecture materials (see additional materials section for lecture materials) to determine what CPT E&M Code to utilize for this ‘new patient’ encounter.

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

Please be sure to validate your opinions and ideas with citations and references in APA format.

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