In the tinnitus case, which CPT code represents the new patient office visit?

In the tinnitus case, which CPT code represents the new patient office visit?

• A. 99212
• B. 99202
• C. 99203
• D. 99201

Answer: (B)

When coding a new patient office visit, you choose from the new-patient CPT codes based on the amount of history, examination, and medical decision making required for the encounter. A straightforward, initial evaluation with a simple complaint like tinnitus typically fits a level two new-patient visit. This level reflects a brief history, a focused exam, and straightforward medical decision making—enough to document the visit without adding the additional complexity that higher levels would require. If the history were extremely brief, the exam minimal, and the medical decision making trivial, a level one might be considered—but in most practical tinnitus evaluations, that level would be too minimal for a new patient encounter. If the case required more extensive history, a broader or more detailed exam, or more complex decision making (for example, multiple symptoms, red flags, or need for additional testing like audiology assessments), a higher level would be more appropriate. And if the patient had seen you before, you’d switch to the corresponding established-patient codes rather than the new-patient set.

When coding a new patient office visit, you choose from the new-patient CPT codes based on the amount of history, examination, and medical decision making required for the encounter. A straightforward, initial evaluation with a simple complaint like tinnitus typically fits a level two new-patient visit. This level reflects a brief history, a focused exam, and straightforward medical decision making—enough to document the visit without adding the additional complexity that higher levels would require.

If the history were extremely brief, the exam minimal, and the medical decision making trivial, a level one might be considered—but in most practical tinnitus evaluations, that level would be too minimal for a new patient encounter. If the case required more extensive history, a broader or more detailed exam, or more complex decision making (for example, multiple symptoms, red flags, or need for additional testing like audiology assessments), a higher level would be more appropriate. And if the patient had seen you before, you’d switch to the corresponding established-patient codes rather than the new-patient set.