The chief complaint and HPI must be attributed to one of these: 2 or more self-limited or minor problems; 1 stable chronic illness, 1 acute uncomplicated illness or injury; 1 stable acute illness; 1 acute uncomplicated illness or injury requiring hospital inpatient or observation. Once you attributed the visit to one of these, you provide a focused exam on the problem(s) and then most likely will not satisfy data element, so provide a specific diagnosis drawn from the exam and reasons why they were there, then jump to what makes this MDM low risk. A perfect example is requesting the patient to take an OTC medication. You need to be specific and example might be: OTC Medication Management: Tylenol 325mg, take 1-2 tablets every 4-6 hours while symptoms last.
The chief complaint and HPI must be attributed to one of these: 2 or more self-limited or minor problems; 1 stable chronic illness, 1 acute uncomplicated illness or injury; 1 stable acute illness; 1 acute uncomplicated illness or injury requiring hospital inpatient or observation. Once you attributed the visit to one of these, you provide a focused exam on the problem(s) and then most likely will not satisfy data element, so provide a specific diagnosis drawn from the exam and reasons why they were there, then jump to what makes this MDM low risk. A perfect example is requesting the patient to take an OTC medication. You need to be specific and example might be: OTC Medication Management: Tylenol 325mg, take 1-2 tablets every 4-6 hours while symptoms last.