[Answered]: Review the AMA 2023 office visit documentation…

Review the AMA 2023 office visit documentation guidelines in the 2023 CPT manual and use the MDM chart that details steps in selecting an office visit E/M code (both files are accessible under Resources in this week’s module). The guidelines can be found at the end of the instructions for this discussion or in the resources for this week’s module. Based on the SOAP note listed below, audit the note for the correct level of visit. CHART NOTE: SUBJECTIVE: The patient is a 35-year-old established male patient seen today with a CC of severe snoring. He says that this has gone on for years and that he’s finally ready to do something about it because he awakens during the night from it and his wife is also losing sleep from his snoring. He says that he wakes up in the morning feeling very tired and notices that he gets very tired during the day. ROS reveals allergies. He denies smoking or alcohol use. He is not currently on any medications. OBJECTIVE: Blood pressure is 134/86. Pulse is 82. Weight is 185. EYES: Pupils equal, round, and reactive to light and accommodation; extraocular muscles intact. EARS & NOSE: Tympanic membranes normal; oropharynx benign. NECK: Supple without jugular venous distention, bruits, or thyromegaly. RESPIRATORY: Breath sounds are clear to percussion and auscultation. EXTREMITIES: Without edema; pulses intact. ASSESSMENT: Possible sleep apnea and high blood pressure PLAN: Patient to undergo sleep study in two weeks. Results to be evaluated by Dr. Jones, ENT specialist to determine whether patient is candidate for laser-assisted uvuloplasty (LAUP) surgery. Patient’s blood pressure has been elevated the last few visits. Patient is encouraged to take blood pressure at home and keep a log. RX sent to CVS Pharmacy for Lisinopril 10 mg PO/qd. Patient to follow up in 3 months. Student must document the following: Level of medical decision making based on two of the three Number or Complexity of ProblemsData to be reviewed/analyzedRisk of complications, morbidity, and/or mortality E/M level of CPT code Document how you chose your E/M level of visit by stating how you determined each level of the medical decision making.