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CC: Shortness of breath

History: A 62-year-old female returns to a family practice having shortness of breath for the last week. It has been two years since her last visit to the practice. She also has nausea, diaphoresis, chest pressure.

Past History: Celebrex® for her arthritis.

Hysterectomy 1 year ago.

Social History: Smoker-No Alcohol-No

Allergies: Penicillin

PHYSICAL EXAM

Vital Signs: BP 195/95 sitting, left arm

General/Constitutional: Mild distress. Some diaphoresis.

Nose/Throat: Mucous membranes normal. Oropharynx appears normal. No mucosal lesions.

Neck/Thyroid: Supple, without adenopathy or enlarged thyroid.

Respiratory: Shallow breathing, no wheezing.

Cardiovascular: Unequal pulses in both arms. Abnormal heart sounds heard.
EKG ordered.

Assessment/Plan

Severe exacerbation of congestive heart failure

Patient is sent to the hospital to be admitted. Will send hospital orders to start her on IV, order chest X-ray and CBC.
A. 99202
B. 99215
C. 99204
D. 99214

How many key components are needed to code a new patient?

Another important difference between the codes is that the new patient codes (99201–99205) require that all three key components (history, exam and medical decision making) be satisfied, while the established patient codes (99211–99215) require that only two of the three key components be satisfied.

What are the initial hospital care codes?

According to CPT, the initial hospital care codes, 99221–99223, are for “the first hospital inpatient encounter with the patient by the admitting physician.” Initial inpatient encounters by other physicians should be reported with either subsequent hospital care codes (99231–99233) or initial inpatient consultation ...

What 3 components are required to assign the code 99205?

E/M code 99205 is used to report office or other outpatient visit for the evaluation and management of a new patient, and requires 3 key components: a comprehensive history; a comprehensive examination; and medical decision making of high complexity.

What are the key components of the office and other outpatient evaluation and management coding quizlet?

Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; Straightforward medical decision making.