On that one, if there is no other chief complaint I would score it like this,
History: Pt returns for follow up from her mastectomy chief complaint,in September 2009 duration.
She is doing well. No complaints, I don't like how this ROS is done at all and would not give credit for a comphrensive ROS even though they have the all others negative comment. I would only give credit for one but since you have no PFSH it wouldn't matter since you can't get any higher than EPF anyway.
ROS: All other systems are negative.
Physical Exam: Full Exam documented. Have no idea what this would support
Impression: NED 1 Dx point Which is going to keep you at Straight Forward on MDMPlan: She will continue in active follow up. I will see her again in six months. A total of 20 minutes were spent with patient on this encounter. If % of time counseling and coordinating was documented as greater than 50% this would be a 99213, since it is not I would code this as a 99212 based on not knowing the exam level. If the exam is EPF or higher it could support a 99213.
Just my take on it,
Laura, CPC, CEMC