If that's what is documented, that's what is coded. My doctors hate when I give them this answer, but I can only code what is documented. You are correct that this is an existing problem that is stable, even with Rx management, you will only get straightforward MDM.
However, with an expanded history and an EPF exam, they can still code 99213, which for "routine" follow-up should be about right for this condition.
Hope that helps.
F Tessa Bartels, CPC, CEMC
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