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Read through the PE and decide if this meets Level 5 billing criteria.

Genera/Constitutional: NC, AT
Eyes: PERRL, EOMI
ENT: moist oral mucosa
Cardiac: irregularly irregular rhythm, tachycardic, no murmurs, no rubs, no gallops
Respiratory: Lungs clear, no respiratory distress, no wheezing, no rales, no rhonchi
Neurological: A&O x 4
Psychiatric: normal affect

a. Level 1
b. Level 3
c. Level 5
d. Level 4

User AndroGuy
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1 Answer

5 votes

Final answer:

The PE findings suggest multiple systems were reviewed and complex scenarios addressed, which could meet Level 5 billing criteria, as this level is for complex and severe conditions.

Step-by-step explanation:

The student has asked whether the Physical Examination (PE) findings meet Level 5 billing criteria. Level 5 billing is typically reserved for the most complex and time-consuming patient visits that require high-level decision-making due to the complexity or severity of the patient's condition. The information provided in the question suggests a thorough examination with multiple systems reviewed, such as general/constitutional, eyes, ENT, cardiac, respiratory, neurological, and psychiatric. Findings like "irregularly irregular rhythm, tachycardic" in the cardiac system, and the absence of any cognitive or language deficits in the neurological and psychiatric reviews are indicative of a more complex scenario. This complexity can qualify for a higher level of billing like Level 5, especially when combined with elements of medical decision-making, such as addressing potential sensory system problems and initiating aspirin therapy.

User Austria
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