Sorry, but without a comprehensive exam documented, the best you can do is 99221. He's got to document the work to get paid for it - "not documented, not done."
I use Trailblazer's E/M audit tool - you can find a copy of it here:
I also made a spreadsheet in Microsoft Excel, and pasted all of the multi-system exam elements into it, so I can just go through and check them off. (We only use 97 rules.) I think that showing the doctors exactly what they got credit for, and (more importantly) what they didn't get credit for, helps to communicate why the code that I'm coming up with is correct. That's just my 2 cents, though...
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