What CPT code was used for the office visit for the newborn cleft palate evaluation?

What CPT code was used for the office visit for the newborn cleft palate evaluation?

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

Answer: (D)

In CPT coding, you choose the level of an office visit based on whether the patient is new or established and how complex the history, exam, and medical decision making are. A newborn who has not been seen by the clinician before is a new patient, and if the visit for evaluating a cleft palate is straightforward—focused history and exam with minimal risk and simple plan—the appropriate level of service is the lowest for a new patient. That translates to a new-patient, office-visit code at the entry level. Higher levels would be used only if the history or exam were more extensive or the medical decision making more complex. An established-patient code would not apply to a newborn new to the practice. So the code used would be the new-patient, straightforward office visit at the lowest level, which corresponds to 99202.

In CPT coding, you choose the level of an office visit based on whether the patient is new or established and how complex the history, exam, and medical decision making are. A newborn who has not been seen by the clinician before is a new patient, and if the visit for evaluating a cleft palate is straightforward—focused history and exam with minimal risk and simple plan—the appropriate level of service is the lowest for a new patient. That translates to a new-patient, office-visit code at the entry level. Higher levels would be used only if the history or exam were more extensive or the medical decision making more complex. An established-patient code would not apply to a newborn new to the practice. So the code used would be the new-patient, straightforward office visit at the lowest level, which corresponds to 99202.