E M Level Determination Mdm And Time Based

An established patient presents with sore throat, fever, and bilateral tonsillar exudate. The provider orders a rapid strep antigen test, reviews the result (negative) during the visit, and despite the negative result prescribes …

Agent classifies Problems as Minimal (one self-limited/minor problem: pharyngitis). Agent then evaluates the Data column as Limited (one diagnostic test ordered and reviewed by the treating provider: rapid strep antigen test). Agent evaluates Risk as Low (prescription drug management: azithromycin)…

An established patient is seen exclusively for acute URI. The encounter transcript contains no provider mention of hypertension, type 2 diabetes, or hyperlipidemia and no medication review, adjustment, or counseling for any chron…

Agent uses only the encounter transcript as the source of truth for addressed problems. It determines that one self-limited problem (URI) was addressed and that HTN, T2DM, and HLD appear in the EHR active problem list but were not addressed in the encounter (provider explicitly stated 'no changes t…

An established patient who received a kidney transplant two years prior is on tacrolimus 2 mg BID and mycophenolate mofetil 750 mg BID for immunosuppression. She presents with three days of nasal congestion, mild sore throat, and…

Agent identifies the immunosuppressed status (tacrolimus plus mycophenolate, post-renal transplant) as a patient-context modifier that elevates the presenting problem complexity beyond self-limited/minor — at minimum to a chronic illness with potential for serious complication or an acute illness i…