Which CPT code best describes an established patient office visit for a problem regarding a mid-level assessment?

Which CPT code best describes an established patient office visit for a problem regarding a mid-level assessment?

• A. 99211
• B. 99213
• C. 99212
• D. 99214

Answer: (C)

The main idea here is how the level of an established patient visit is determined: based on history, examination, and medical decision making (MDM). For a problem-focused visit on an established patient where the documentation shows a straightforward evaluation and a simple plan, the level that fits is 99212. This code is designed for established patients with a problem-focused history and exam and straightforward MDM, meaning the clinician gathered only essential information and the management plan was uncomplicated. If the chart showed more extensive questioning, a broader examination, or a more complex decision making process, a higher level would be appropriate (99213 for expanded problem-focused history/exam with low to moderate MDM, or 99214 for detailed history/exam with moderate to high MDM). On the other end, 99211 is typically used for nurse-only visits without physician involvement in the decision making. So, given a mid-level problem-focused assessment for an established patient, 99212 best matches the described scenario.

The main idea here is how the level of an established patient visit is determined: based on history, examination, and medical decision making (MDM). For a problem-focused visit on an established patient where the documentation shows a straightforward evaluation and a simple plan, the level that fits is 99212. This code is designed for established patients with a problem-focused history and exam and straightforward MDM, meaning the clinician gathered only essential information and the management plan was uncomplicated.

If the chart showed more extensive questioning, a broader examination, or a more complex decision making process, a higher level would be appropriate (99213 for expanded problem-focused history/exam with low to moderate MDM, or 99214 for detailed history/exam with moderate to high MDM). On the other end, 99211 is typically used for nurse-only visits without physician involvement in the decision making. So, given a mid-level problem-focused assessment for an established patient, 99212 best matches the described scenario.