If this is the ONLY piece of documentation on which you are trying to base your E/M code ... No.
For a 99212 you need two of the following three:
Problem focused Hx
Problem focused Exam
If this snippet of documentation you provided is all you are basing your coding on, then all you have is
One component of MDM (risk - for Rx)
So, no you can't squeeze a 99212 out of this. You can, get a 99211, which only requires a chief complaint. And YES, MDs can bill this code. Just because it is a low-level E/M that "may not require" the services of a physician (quote taken direct from CPT), doesn't mean that it is strictly used for "nurse visits."
If you do have additional documentation that you can pull your bullet points from, then of course you can bill the separate E/M code as appropriate.
And don't forget the -25 modifier on your E/M code.
F Tessa Bartels, CPC, CPC-E/M
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