CPT code selection
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School
University of North Georgia, Dahlonega *
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Course
4150
Subject
Medicine
Date
Feb 20, 2024
Type
docx
Pages
2
Uploaded by MagistrateValorViper10
Student Name: Rachel Jones
Case
CPT Code
Justification
A 32 year old female was referred to the office of a primary care provider (PCP). She was just recently seen in the emergency room for chest pain and she was instructed to find a PCP. She has been previously diagnosed with Huntington’s disease and is seeing a specialist but she has not had a PCP in a while. Her Huntington’s disease causes her many problems and she has difficulty walking. Today, the provider diagnosed her with gastro-esophageal reflux disease after taking her history and completing a physical exam. No tests were ordered today, but she was instructed to eat a bland diet and recommended that she take Zantac which she can get from her local store. 99202
New patient
1)
Expanded problem focused history- chief complaint (chest pain), a brief history of present illness (Huntington’s and chest pain)
2)
Expanded problem focused exam- (physical exam)
3)
Straight forward medical decision making- (Patient risk
low, no prescription medications given)
(Layher, 2018, slide 27)
A 26 year old patient who is seen in the practice very year comes
in because he twisted his ankle playing a pick-up game of basketball yesterday. The PCP examined his ankle, put an ACE wrap on the ankle and gave him some crutches. The PCP told the patient that Tylenol or ibuprofen were ok to take. An appointment was made for 3 days to see how he was doing
99212
Established patient
1)
Problem focused history- chief complaint (twisted ankle)
2)
Problem focused exam- ankle examination
3)
Straight forward medical decision making- (patient risk low, no prescription medications given)
(Layher, 2018, slide 25)
A 48 year old man returns to the office. Today he is complaining of a sore throat, cough and congestion that has been going on for about a week and a half. The symptoms got a bit better but then got worse again. This patient has a history of hypertension that is well controlled on medication. Today, the PCP did a strep
and flu test in the office. He reviewed the over-the-counter medications that are safe to take for colds for individuals who have hypertension. The PCP prescribed an antibiotic and asked that the patient come back in two days to be evaluated. 99213
Established patient
1)
Expanded problem focused history- chief complaint (sore throat, cough, congestion), brief HPI (symptoms better then worse, history of hypertension and medications)
2)
Expanded problem focused exam- strep and flu tests
3)
Low complexity level decision making- review of over the counter medications and a prescription antibiotic (Layher, 2018, slide 25)
A 58 year old woman comes into the office to get an 99215
Established patient
examination and clearance for an upcoming knee replacement surgery. She has being a patient at the clinic for many years and has a history of diabetes, hypothyroidism, hypertension, hyperlipidemia, osteoarthritis, and obesity. She has recently lost
50 pounds in preparation for the surgery. The PCP reviewed a recent chest x-ray, ECG diagnostic studies. She also reviewed the results of labs including CBC, Electrolytes, thyroid studies, and a lipid panel. The PCP examined her from head to toe. At the end of the visit, the PCP gave the patient clearance for surgery and documented this extensively for the surgeon. 1)
Comprehensive history – been a patient for years, detailed history 2)
Comprehensive exam- reviews of past exams and labs,
as well as a comprehensive physical
3)
High complexity medical decision making- extensive documentation and clearing patient for invasive surgery
(Layher, 2018, slide 26)
References:
Layher, J. (2018). Coding: What You Need To Know. https://www.acoi.org/sites/default/files/uploads/Layher.pdf
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