Based on the documentation above and 95 guidelines......I would code this report as a 99213. The HPI is lacking so you would need to pull something for ROS, making the History, expanded prob focused,
the Exam is expanded problem focused and the MDM is moderate..........you need 2 out of three so I would code this as a 99213.
Let me know if you agree,
Mary Lou Saunders, CPC
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