Detailed History (4 HPI, >2 ROS, >1 area PFSH)
Detailed exam (>2 body areas/organ systems - 1995, or 12 bullets - 1997)
Low MDM (Best 2/3: >2 points in diagnoses/management options, >2 points in data reviewed, and/or Low risk)
Right off the bat, I see several HPI:
Had girlfriend/boyfriend who tested positive for gonorrhea. (HPI Context)
He/she thinks that he/she may have some urinary hesitancy (HPI Associated signs/symptoms, or ROS: Genitourinary - since the doctor didn't document a separate ROS, you've got to take it from somewhere, so this statement would probably be best)
and sometimes feels like he/she has a hard time finishing urination. ("sometimes" = timing, "has a hard time finishing urination" = quality, or possibly severity, depending on how you look at it)
No other sx.
He/She does have hx genital warts-dx 3 years ago. (Personal History)
You've also got some additional family and social history, so the PFSH is not in question. According to Deborah Grider, a single statement can't be counted as both HPI and ROS, but that's a point of contention amongst auditors, so it's considered 'debatable', to some. I think that it's a bit of a moot point, here, because you don't have enough ROS to be considered "extended" in the first place, so the encounter would be disqualified for a 99203 based on that. He made no mention of specific symptoms, aside from the genitourinary system. "No other sx" is too vague to indicate that ROS was performed on any other systems. Had he stated "All other systems negative for symptoms", then it would have been counted as complete, but documentation guidelines are very clear on making that distinction, so your provider may want to reconsider the way that he words things, in the future. Genital warts are not a current problem, and without mentioning the presence or absence of a current outbreak, I wouldn't count it as anything more than personal history.
As for the exam - you can reach detailed by 1995 guidelines, since 2-7 body areas/organ systems are all that's required, but you're nowhere near 12 bullets if he's following 97 rules. In fact, there are barely enough there to qualify for an EPF exam, if you're counting bullets.
MDM is easily low - 1 point under Dx/treatment options (either 1 point for # of diagnoses, or 1 point for the Rx drug management)
2 points for data (>4 labs ordered for a single problem)
Moderate risk (Rx drugs)
So, I agree with the 99202, because the documentation was kind of shoddy. I noticed the prescriptions at the bottom, which appear to be for allergies - there's absolutely no mention of them in the history or exam, so the provider missed an opportunity to qualify for a higher level of E/M there, too. You can only code what he wrote down, so if he wants to get paid for all of his work, he should make it a point to document all of it. Hope that helps!
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