Having trouble coding this case and need clarification on the exam part. The patient came in for recheck of the ears (seen 14 days earlier). During the exam, the physician reviews 5 body areas (neck, chest, abdomen, back and extremities) and 6 organ systems (eyes, ears/nose/throat/mouth, lungs, cardio, skin and neuro) and documents a short statement about each.
Since we have moderate decision making (Rx meds), would this be considered a level 4 (99214) since the exam is comprehensive.
Do it seem reasonable to do a comprehensive exam again, 14 days later?
Since we have moderate decision making (Rx meds), would this be considered a level 4 (99214) since the exam is comprehensive.
Do it seem reasonable to do a comprehensive exam again, 14 days later?