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The patient record indicates that a problem-focused history and examination were done. When this is combined with the level of decision-making complexity you arrived at for this patient, what is the correct CPT code for the case?

a. CPT Code: 99213
b. CPT Code: 99214
c. CPT Code: 99215
d. CPT Code: 99217

User Smartkid
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Final answer:

The correct CPT code for a patient record indicating a problem-focused history and examination, when combined with a known decision-making complexity, is suggested to be CPT Code: 99213, assuming the decision-making complexity is low to moderate.

Step-by-step explanation:

If a patient record indicates that a problem-focused history and examination were performed and this is combined with the level of decision-making complexity you have determined for this patient, the correct Current Procedural Terminology (CPT) code would typically reflect the extent of each of these components. However, without knowing the specific level of decision-making complexity, it's not possible to provide the precise CPT code. Assuming you have assessed a low to moderate complexity in decision-making given the context of this question, the closest option would be CPT Code: 99213, which is used for an office or other outpatient visit for the evaluation and management of an established patient that typically requires at least two of these three key components: a problem-focused history; a problem-focused examination; and medical decision making of low complexity.

User Jglasse
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