Can anybody tell me if there is documentation somewhere that supports always using the MDM along with either History or Exam in order to come up with an established patient E&M level? For example, patient comes in with a straightforward MDM (99212) but history and exam support a 99213. Do we give a 99213 just because the Hx and Exam support this but Medical Decision Making or medical necessity support a lower level?? Please advise...... Thanks!!!!