Analyze this note and determine the appropriate CPT E/M billing code using 2021 E/M guidelines for an ESTABLISHED patient.
MDM Component Assessment
A. PROBLEMS ADDRESSED
·   Straightforward: 1 self-limited/minor problem
·   Low: 2+ self-limited/minor problems OR 1 stable chronic illness OR 1 acute uncomplicated illness
·   Moderate: Chronic illness with exacerbation/progression OR 2+ stable chronic illnesses OR undiagnosed new problem OR acute illness with systemic symptoms OR acute complicated injury
·   High: Chronic illness with severe exacerbation OR illness posing threat to life/bodily function
B. DATA COMPLEXITY
·   Low: Assessment requires independent historian, None or one piece of data reviewed/ordered along with 
·   Moderate: Any combination of two tests ordered, test results reviewed, or prior external notes reviewed along with assessment requiring an independent historian
·   High: Meets criteria for Moderate AND discussion with external physician regarding interpretation of tests OR independent test interpretation
C. RISK LEVEL
·   Minimal: Minimal risk from testing/treatment
·   Low: OTC medications, rest, observation
·   Moderate: Prescription drugs, Dx or Rx limited by social factors
·   High: Decision regarding hospitalization
2-of-3 Rule
Overall MDM = level met by at least 2 of 3 components.
·   Straightforward = 99212
·   Low = 99213
·   Moderate = 99214
·   High = 99215
Modifier 25 Check
Add modifier 25 for a separately identifiable E/M service during a Well Child Check/Routine child health examination. 
Output Format
Problems: [Level] [Brief explanation]
Data: [Level] [What was reviewed/ordered]
Risk: [Level] [Treatment risk level and why]
MDM Score: Problems ([Level]) + Data ([Level]) + Risk ([Level]) = [Overall Level] (based on 2 of 3)
Final Code: 99XXX
Modifier 25 Format:
Modifier 25: Well visit with separate E/M for:
 - [Problem 1] ([brief intervention])
 - [Problem 2] ([brief intervention])
Critical Coding Rules
1. Ordering any culture (e.g., strep, urine) implies consideration of prescription management and elevates Risk to at least Moderate.
2. Acute illness with systemic symptoms + any culture ordered = 99214 (Moderate Problems + Moderate Data + Moderate Risk).
3. Assume Assessment requiring an independent historian is always true.
Examples
Viral URI (simple) Runny nose, cough. Exam: clear. Plan: supportive care.
Problems: Low (1 acute uncomplicated) Data: Minimal Risk: Low (supportive care only) MDM Score: Problems (Low) + Data (Minimal) + Risk (Low) = Straightforward (based on 2 of 3) Final Code: 99212
Strep Throat Sore throat, fever 102F, body aches. Exam: exudates. Plan: strep test, amox if positive.
Problems: Moderate (Acute illness with systemic symptoms) Data: Moderate (test ordered) Risk: Moderate (prescription antibiotic) MDM Score: Problems (Moderate) + Data (Moderate) + Risk (Moderate) = Moderate (based on 2 of 3) Final Code: 99214
UTI with Fever Toddler with fever 102.5, crying with urination. Exam: suprapubic tenderness. Urine dipstick positive. Plan: send urine culture.
Problems: Moderate (acute illness with systemic symptoms) Data: Moderate (2 tests ordered and independent historian) Risk: Moderate (culture implies potential prescription) MDM Score: Problems (Moderate) + Data (Moderate) + Risk (Moderate) = Moderate (based on 2 of 3) Final Code: 99214
Well Visit + Ear Infection 5yo well child check. Parent reports ear pain, fever x2 days. Exam: acute otitis media. Plan: amoxicillin.
Problems: Low (1 acute uncomplicated) Data: Minimal Risk: Moderate (prescription) MDM Score: Problems (Low) + Data (Minimal) + Risk (Moderate) = Low (based on 2 of 3) Final Code: 99393 + 99213-25 Modifier 25: Well visit with separate E/M for: - Acute otitis media (amoxicillin)
Well Visit + Multiple Issues 18-month well child check. Also has URI and diaper rash. Exam: clear rhinorrhea, diaper dermatitis. Plan: supportive care for URI, barrier cream for rash.
Problems: Low (2 self-limited problems: URI, diaper rash) Data: Minimal Risk: Low (OTC/supportive care) MDM Score: Problems (Low) + Data (Minimal) + Risk (Low) = Low (based on 2 of 3) Final Code: 99392 + 99213-25 Modifier 25: Well visit with separate E/M for: - Viral URI (supportive care) - Diaper rash (barrier cream)
Asthma Exacerbation, using albuterol 4-5x/day, night cough. Exam: mild wheezing. Plan: increase Flovent.
Problems: Moderate (chronic with exacerbation) Data: Minimal Risk: Moderate (prescription adjustment) MDM Score: Problems (Moderate) + Data (Minimal) + Risk (Moderate) = Moderate (based on 2 of 3) Final Code: 99214
Multiple Minor Issues Viral URI, diaper rash, small bruise. Exam unremarkable. Plan: supportive care, barrier cream, observation.
Problems: Low (3 self-limited problems) Data: Minimal Risk: Low (OTC only) MDM Score: Problems (Low) + Data (Minimal) + Risk (Low) = Straightforward (based on 2 of 3) Final Code: 99212
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