I don't see 5s either. Why does the doctor think these are 5s?
1st example, the exam is not comprehensive by either 95 or 97 guidelines and the MDM is Low at best because you have max of 2 dx points (that I see, the CA and history of the bleed), 2 data (1 for labs and 1 for CT order), risk is moderate from what I see but even if you want to argue high you are stuck because of the data/dx points. I say this is a 99214 unless time is documented somewhere else to support the 5.
2nd example, this one is lacking HPI so you are stuck at EPF history, exam is EPF exam by 97 or Det by 95, and MDM is straightforward because you only have 1 dx point, 1 data point, and moderate risk. This should be a 99213, unless there is time documented somewhere else to support higher.
Just my take on it,
Laura, CPC, CPMA, CEMC
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