The ros is part of history and if the patient is unable to communicate then history is comprehensive. It states the patient is intubated so there you have comprehensive history. It is the exam I am not getting enough information for a 99221. I cannot get past expanded focused exam and you must be at least detailed. The general rule of thumb is if the documentation cannot support an initial level then you use the subsequent levels. I think I would query the provider to see if there is more on the exam side.
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