If this is the note I am confused.
Was this visit just to go over results of the MRI? I would say this needs to be based on time because this is a bunch of history, no clear cut HPI, no exam, and I am coming up with Low complexity MDM.
I don't see anyway to get a 99214 out of this. I don't see time so I am guessing it wasn't documented and is not an option.
This looks more like a summary letter to another provider, not an indvidual visit. I would not feel comfortable billing anything based on this.
Sorry not much help here,
Laura, CPC, CEMC
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