When determining a level of service, you can use the key components (HPI, Exam, and MDM) or time. For your example, you should not upcode to 99214 since the time documented was only 15 minutes. If the documentation for the chief complaint meets a 99213 and then the provider documented an additional 15 minutes of counseling, you could use the 99401. If the provider documented an additional 30 minutes, you could also use the prolonged service code 99354.
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