A new patient visits the internal medicine clinic today for diabetes, chronic constipation, arthritisand a history of cardiac disease. The provider performs a detailed history, comprehensive examand a medical decision making of moderate complexity. What CPT® code is reported?

a.99213
b.99214
c.99203
d.99204

c.99203

Explanation:

The phrase “three of three” means that components: history, exam, and medical decision-making (MDM)  must meet or exceed the requirements of the E/M code descriptor while “two of three” means two of the components must meet or exceed the code requirements. For a new patient three of the components are used

A method used to provide the correct E/M service level and code is writing the letters H, E, M (H = History, E = Exam, M = MDM), and marking the level of each key component as you go through.

For the above question: since the patient is new; the three components would be used

History: detailed = supports a level 3 new patient service

Exam: detailed = supports a level 3 new patient service

MDM: moderate = supports a level 4 new patient service

So:

H: Det = 3

E: Det = 3

M: Mod = 4

In this case, because all three components must meet the code descriptor requirements, proper coding is 99203.

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