Patient has elevated PSA (chronic stable) and also has a family history of prosate cancer. We are seeing him back in 6 months with repeat PSA. Is this a 99212 or can it somehow be a 99213 because of the family history of prostate cancer?
Based on the info provided and the assumption this is for an office visit. I would consider the chronic stable elevated PSA to be a stable chronic illness, which is a low level of number/complexity of problems. Ordering of the repeat PSA would be a minimal level of data. With no further treatment and just keeping an eye on it, I would consider to be a minimal risk. With low #/complex probs, minimal data, and minimal risk, I would consider this to be a level 2.