A new patient at a county clinic has a medically appropriate history and exam with moderate medical decision making. Under current office/outpatient E/M guidelines, how is the level primarily selected?
Select an answer to reveal the explanation.
Short Explanation
New clinic patient + moderate brain-work (MDM) is the modern leveling story—or total time if that’s how they documented. You’re not digging through old bullet-count archaeology or grabbing inpatient codes for a county clinic visit.
Full Explanation
Current office/outpatient E/M guidelines allow leveling by medical decision making or total time on the date of the encounter. A new patient with moderate MDM maps to the moderate-level new-patient office/outpatient code when MDM is used. History and exam must be medically appropriate but are not scored by legacy bullet counts as the primary level driver. Inpatient categories and automatic highest-level selection without MDM/time support are incorrect.