What CPT code was used for the podiatry office visit for evaluation of a chronic foot ulcer?

What CPT code was used for the podiatry office visit for evaluation of a chronic foot ulcer?

• A. 99202
• B. 99203
• C. 99204
• D. 99212

Answer: (B)

Office E/M coding hinges on two things: is the patient new to the clinician, and the level of service based on history, exam, and medical decision making. For a podiatry visit where the patient is being evaluated for a chronic foot ulcer, the critical factor is whether this patient has been seen by this podiatrist before. If the patient is new to the practice, you use a new-patient office visit code, and the level is determined by how complex the history, exam, and decision making are documented. A chronic foot ulcer usually requires a thorough wound assessment and a care plan, which typically amounts to a moderate level of complexity. When the encounter is new to the clinician and the documentation supports moderate complexity, the appropriate choice is the new-patient code at a moderate complexity level. If the patient were already established with the practice, you would use an established-patient code, with the level determined by the same criteria, and the required documentation would influence whether the level is lower or higher.

Office E/M coding hinges on two things: is the patient new to the clinician, and the level of service based on history, exam, and medical decision making. For a podiatry visit where the patient is being evaluated for a chronic foot ulcer, the critical factor is whether this patient has been seen by this podiatrist before. If the patient is new to the practice, you use a new-patient office visit code, and the level is determined by how complex the history, exam, and decision making are documented. A chronic foot ulcer usually requires a thorough wound assessment and a care plan, which typically amounts to a moderate level of complexity. When the encounter is new to the clinician and the documentation supports moderate complexity, the appropriate choice is the new-patient code at a moderate complexity level. If the patient were already established with the practice, you would use an established-patient code, with the level determined by the same criteria, and the required documentation would influence whether the level is lower or higher.