Per 1995 guidelines you have
EPF exam (BP recorded and "chest clear")
MDM - LOW (2 problem pt for established problem worsening - "BP Up" / Moderate risk for Rx management)
This equals a 99213 established patient visit per 1995 guidelines. (But I agree that this is pretty sad documentation ... not to mention hard to read.)
F Tessa Bartels, CPC, CEMC
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