(Full Case:Established patient office visit.

This is anestablished patientoffice visit coded byMDM(no total time documented). Problems addressed include achronic condition(multinodular goiter/thyroid nodules) requiring evaluation with malignancy risk considerations (family history of thyroid cancer and palpable mass). The plan includes apercutaneous biopsy, which is aminor procedureplanned, increasing management complexity compared with reassurance-only follow-up. Data reviewed includes at leastreview of an ultrasound from last weekshowing multiple thyroid masses consistent with multinodular goiter (outside test review), which supports data element involvement. Risk is at leastmoderatebecausedecision for a minor procedureis documented in the plan (with procedure-related risk assessment implicit). While ROS is largely negative and exam is not extensive enough alone to drive code selection, MDM supports amoderate leveloverall, aligning with99214for established patients. It is more complex than 99213 due to planned invasive diagnostic procedure and risk assessment, but does not reach 99215 because there is no high-risk management (e.g., major surgery decision, severe exacerbation, or intensive data complexity).