Question

Patient referred for consult by PCP regarding right knee pain. Expanded problem-focused history and exam and low MDM were performed and no significant orthopedic diagnosis was made following diagnostic x-rays. A prescription for pain medication was written and the patient was discharged back to their PCP for additional evaluation and treatment if needed. Written documentation of referral, requesting physician, and written report to PCP are documented.

A. 99213
B. 99242
C. 99241
D. 99252

Answer 1

The medical scenario provided describes an outpatient consult with a problem-focused history and exam and low MDM for knee pain. The appropriate CPT code for this situation is 99213.

Step-by-step explanation:

The scenario described involves a patient who was referred by a Primary Care Physician (PCP) to a consultant for right knee pain. An expanded problem-focused history and exam were performed along with a low Medical Decision Making (MDM). No significant orthopedic diagnosis was made, and after diagnostic x-rays, a prescription for pain medication was given. Following this, the patient was discharged back to the PCP for further evaluation and treatment if necessary. All procedures, including the referral, consulting physician, and the written report to the PCP, were documented. The code that best describes this scenario is A. 99213, which pertains to an office or other outpatient visit that includes an expanded problem-focused history and examination, and low-level MDM.