Evaluation and Management Coding Practice: S: Monica Sullivan was seen in the office by Dr. White on 12/13 for the second time. She presented with a chief complaint of dizziness and weakness; she stated that she wanted to have her blood pressure checked.

O: Patient has been on Vasotec 5 mg and Hydrodiuril 25 mg. BP has been going up at home. Patient has felt ill, weak, and dizzy, with headache for three days. Cardiovascular exam was normal. BP of 130/110 and pulse rate of 84. Her temperature is 98.6°F and normal.

A: Accelerated hypertension. Bell's palsy.

P: Increase Vasotec to 5 mg a. m. and 2.5 mg p. m. SMA & CBC.

E/M category/subcategory: Office or Other Outpatient Services, Established Patient

Determine the extent of history obtained: ?

Determine the extent of examination performed: problem focused

Determine the complexity of medical decision making: moderate complexity

CPT E/M code: 99212

---what is the extent of history obtained for this case?