A minor, self-limited probelm will go away without any treatment.
If the patient is having a reaction to medication, this will NOT go away without treatment (even if the only treatment is discontinuing the medication causing the side effect). So this is a new problem (unless the patient has complained of this side effect with this medication previously) with no additional workup. And your risk is moderate because of Rx management (new script).
So you have moderate decision making.
With an EPF history the highest level of visit you can have is 99213 in any case.
Hope that helps.
F Tessa Bartels, CPC, CEMC
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