A patient is seen in the office. His last visit was four years ago, although documentation in his record reveals that the physician has ordered prescription medicine several times in the past three years. The physician performed an expanded problem-focused history; expanded problem focused exam; straightforward medical decision-making. Which CPT code should be reported for the E/M service?

Question

Quizplus · Accepted Answer

The correct CPT code is 99202, which is for a new patient office or other outpatient visit that includes an expanded problem-focused history and examination, and straightforward medical decision-making. Since the patient has not been seen in the office for over three years, for coding purposes, he is considered a new patient despite the physician ordering prescription medicine for him during that time.

A Patient Is Seen in the Office