I'm afraid I disagree with all of you. If the problem is stable or resolved, then the very best you can do, unless there was another problem addressed, is a 99212. Using MDM as the overarching criteria, you need two of the three MDM components to reach your level of MDM. With a stable or resolving problem, even with a prescription, the best you can get (I don't see any data points) is straightforward MDM. If it's worsening, then I would agree with a 99213, but only if the HPI or exam meet the level, based on medical necessity.
Unless other problems are present, a detailed or comprehensive exam might not meet medical necessity in this example. (mentioning them doesn't necessarily make them count-able). And just because organ systems or body areas are mentioned, the 95 Detailed guidelines require that at least one of those systems (preferably the ENT system, in this case) should be documented in detail. Six organ systems and five body areas for an ear recheck? I'd be concerned about giving credit for exam components that are unrelated to the chief complaint, and not linked to another presenting problem. I always use this example to make a point to my providers, "Why are you doing a gyne exam when the patient has a sore throat". Ususally, they've just forgotten to mention that the patient also has another GU-related complaint, but you want to point out that over-documentation to drive a higher code can be just as troublesome from a compliance perspective as not documenting at all.
Pam Brooks, MHA, CPC, PCS, COC
Dover, NH 03820
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