Not every patient will require a comprehensive history and examination. It sounds as though this has been identified as a pattern. I would want to review the E/M guidelines with the provider and show them to start with the medical necessity of the visit and to document the history and examination accordingly.
If you are looking at black and white E/M guidelines, it appears this might be a 99213; however, I would ask the provider why they see this as a higher level visit (did something else occur in the exam room which did not make it into the documentation?). This could be the perfect educational opportunity for both you and the provider!
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