Question

A 59-year-old with chest pain. History of small vessel disease. Seen in office today with chest pain and sent for admission and further evaluation. Admission H & P reveals no Hx MI, negative heart cath 3 years ago. Has HTN and diabetes. Physical exam: VS stable, heart, abdomen, extremities, normal. EKG shows sinus rhythm, chest x-ray normal, cardiac enzymes normal. Admitted for further evaluation and treatment. Detailed Hx and exam are documented.

A. 99213-25, 99221
B. 99221
C. 99214
D. 99223

Answer 1

The question asks for the correct medical billing code for a 59-year-old patient admitted with chest pain and a history of small vessel disease, HTN, and diabetes. The patient's workup was normal and they were admitted for further evaluation.

Correct option is B

Step-by-step explanation:

The question provided is about choosing the correct Current Procedural Terminology (CPT) code for a patient who is 59 years old with a history of small vessel disease, hypertension (HTN), and diabetes, presenting with chest pain. The patient's admission history and physical (H & P) reveal that they have stable vital signs, a normal physical examination with a sinus rhythm on the EKG, a normal chest x-ray and no elevation in cardiac enzyme levels. The diagnosis process for Coronary Artery Disease (CAD) includes a variety of tests to rule out conditions such as stable angina, unstable angina, myocardial infarction, and heart attack, which are all associated with symptoms like chest pain, shortness of breath, and potential nausea.

Treatment of CAD may require medication management, lifestyle changes, and possibly interventional procedures depending on the severity and progression of the disease. The appropriate CPT code for an initial hospital inpatient care service with detailed history and examination and medical decision making of low complexity is 99221, aligning with the scenario mentioned.