Question

What code would you use for an *Established* Patient when doing a "*Focused* history, *Focused* exam, *Straightforward* medical decision; Presenting problem: self-limited to minor: avg. time: 10 minutes"?

Answer 1

The appropriate code for an Established Patient with a focused history, exam, and straightforward decision making for a minor problem, average time 10 minutes, could be CPT codes 99212 or 99213, based on the complexity and guidelines for that year.

Step-by-step explanation:

To code for an Established Patient with a focused history, focused exam, and straightforward medical decision making, you would typically use CPT codes from the range that describes office or other outpatient visits for the evaluation and management of an established patient. The particular CPT code within that range is chosen based on the complexity of the visit, the patient's condition, and the time spent with the patient. For a problem that is self-limited or minor, with an average time of 10 minutes, you may consider a lower level CPT code such as 99212 or 99213, if the requirements for these codes fit the service provided. It is essential to review the current year's CPT coding guidelines as these codes can change and the definition of each level of service may vary slightly from year to year.