I have a doctor that saw 3yr twins both the same day for a preventive visits. The doctor suggested that the vision check be repeated with question mark like they had trouble performing that aspect that day. There is nothing else in the notes saying they attempted it or not. Then a month later the patients come back in for the immunizations that were due and the doctor gives them himself. He give a vision test as well. He notes this as a problem focused exam 99212. The thing I don't agree with is the vision test is not listed as the CC the Immunization is listed as the reason for visit. It appears to me that just because he is a doctor performing the administration of the vaccine and talked to them about not sleeping at night that he is trying to charge a 99212. Here is the SOAP for both visits.
Tell me what you think should he be able to bill a 99212 because he also did an eye exam and talked about not sleeping all through the night?

Exam 1
Almost 4 y/o, first time seen here. Twin A, 36 1/2 weeks 5 lb 3 oz without Cx. Normal development. No chronic illness, medications, allergies. ROS neg. M, F with allergies. Recently separated, living with her folks and younger sib.

Healthy girl, 80%s. Fundus normal, ENT clear. Heart regular without murmur. No organomegaly, scoliosis. Skin clear, good ROM extremities.

Healthy 3, almost 4 y/o

Pentacel, MMR, Varivax, PCV-13
RTC 1 month for Hep B, Influenza; Repeat vision screen; ?cooperation.
Otherwise RTC 1 year routine WCC.

Exam 2
In with new caretaker. Family American Indian, Ogalala Lakota from Pine Ridge South Dakota. Some awakening at night issues, discussed.

Passed vision fairly well; 20/40 - 20/50

Immunization catch-up: MMR, Varivax, Hep A, Influenza