A physician who is part of a medical group practice saw a patient today who had not been treated by the practice for 7 years. The patient presented with a persistent cough and some congestion. The physician performed a medically appropriate history and examination. The patient is diabetic, which is controlled with diet and medication. The physician ordered lab work and a CXR. The physician prescribed medication for the cough and congestion and gave the patient a new prescription for his diabetic medication. The patient was asked to return in 1 week. Provider used low level of decision making. Choose the appropriate evaluation and management code for today's encounter:

Question

Quizplus · Accepted Answer

99203 is the correct code for a new patient office or other outpatient visit that requires these three key components: a detailed history, a detailed examination, and medical decision making of low complexity. Since the patient had not been seen by the practice for 7 years, they are considered a new patient. The detailed history and examination, along with low complexity decision making, align with the requirements for 99203.

A Physician Who Is Part of a Medical Group Practice