A 42-year-old woman sees her OB/GYN for her regular annual GYN exam. She is healthy and in no distress, and there has been no change since last year's exam. Exam was detailed, history was detailed, and medical decision-making was straightforward.

Question

Quizplus · Accepted Answer

The appropriate code for an annual GYN exam for an established patient is 99396. This code includes a comprehensive history and exam, as well as medical decision-making of low to moderate complexity, which is appropriate for a healthy patient with no changes since last year's exam. The other codes listed are not appropriate for this scenario because they either do not include a comprehensive exam (99202) or are for a preventative medicine visit for a new patient (99386) or an established patient with a new problem (99214).

A 42-Year-Old Woman Sees Her OB/GYN for Her Regular Annual