History - you have ROS there - it can be shared with your chief complaint: back pain = musculoskeletal. HPI - location (low/Lumbar), quality (aching), and perhaps context, if you count the rhizectomy as being specific enough to provide insight into the circumstances surrounding the cause of the chief complaint - it doesn't matter either way, though. You have less than 4 HPI, limiting you to an EPF Hx, which also requires a minimum of 1 ROS, which you've also got. No PFSH is required. MDM is Low. 1 established problem, no additional workup planned (meaning, it was a straightforward decision - he didn't need to diagnose her, or formulate a plan of action - it was either going to be 'yes you can have surgery', or 'no you can't', and not the start of a trial and error process attempting to figure something out). Or, if you count the # of management options instead of the # of diagnoses, you get 1 point for drug management, and 1pt for patient education regarding self-care (or conservative measures, depending on how you look at it), which equals a Low score in that category. No data ordered/reviewed= SF for its category. Yes, that counts as Rx drug management on the table of risk, placing your highest risk level as moderate, making the overall MDM is Low.
So, for an established patient who's having surgery done by another provider the next day, you could report up to a 99213. If your provider is doing the surgery, you can't report anything, unless the decision for surgery was made at that time (which doesn't appear to be the case). Hope that helps!
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