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Patient presents for admission with dehydration and uncontrolled diabetes. Detailed history and exam performed and moderate MDM.

A. 99222
B. 99223
C. 99214
D. 99221

User Scribe
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1 Answer

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Final answer:

The correct billing code for a patient presenting for admission with dehydration and uncontrolled diabetes after a detailed history, exam, and moderate MDM would be 99222, as it requires a comprehensive history, comprehensive exam, and moderate complexity medical decision-making.

Step-by-step explanation:

The student's question relates to the correct billing code for a patient who presents for admission with dehydration and uncontrolled diabetes, for which a detailed history and exam were performed, and moderate MDM (Medical Decision-Making) was necessitated. The codes provided are:

  • A. 99222 - Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: a comprehensive history; a comprehensive examination; and medical decision making of moderate complexity.
  • B. 99223 - Initial hospital care, for the evaluation and management of a patient, which requires these 3 key components: a comprehensive history; a comprehensive examination; and medical decision making that is of high complexity.
  • C. 99214 - Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; and medical decision making of moderate complexity.
  • D. 99221 - Initial hospital care, for the evaluation and management of a patient, which requires these 3 key components: a comprehensive history; a comprehensive examination; and straightforward medical decision making.

Given the detailed history and exam as well as the moderate level of medical decision making, the correct billing code would most likely be 99222, as it corresponds with the services provided according to the scenario described.

User Kumar
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