What he says, "patient is healthy and cleared for surgery" denotes the preoperative assessment notes to say that he is fit for surgery. It is not the presenting problem or illness that goes into the history/examination for the presenting problem.What goes into the medical record of E/M Service is the later part of his notes of evalation,H/O HTN, and the mild diabetes, the examiantion related to the surgery cause and the preexisting deceases.
He has taken detailed history and comprehensive examination and the MDM level is with moderate complexity with assessment for surgery, from the info provided.So the E/M Service code is 99214.
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