Question

A 58-year-old female returns to practice for first time in 4 years with abdominal pain, primarily mid-abdominal. Symptoms present for approximately 2 weeks. Patient reports nausea, vomiting, and diarrhea. No chest pain, SOB, rectal bleeding. Patient has been treated prior to this date for arthritis and hypertension. VS normal. Heart unremarkable, chest clear. Abdomen, soft, tender. Lab shows Hct 43, WBC 7100. Acute abdominal pain, cannot rule out appendicitis. Set up for abdominal ultrasound 10:00 AM tomorrow morning.

A. 99214
B. 99213
C. 99204
D. 99202

Answer 1

The best choice for coding the patient's encounter based on the provided information is option B. 99213.

Step-by-step explanation:

The best choice for coding the patient's encounter based on the provided information is option B. 99213.

The patient presents with abdominal pain, nausea, vomiting, and diarrhea, suggesting a gastrointestinal issue. The abdominal pain is primarily mid-abdominal and has been present for approximately 2 weeks. The patient has been treated previously for arthritis and hypertension and is currently within normal vital signs.

With these symptoms and findings, a level 3 office visit (99213) is appropriate. This code represents an established patient with a problem of low to moderate severity, requiring a detailed history, an expanded problem-focused examination, and straightforward medical decision-making.