Which CPT code is appropriate for a new patient seen today for a mild rash on the left arm, with no other complaints and instruction to use an over‑the‑counter anti‑rash cream?

Which CPT code is appropriate for a new patient seen today for a mild rash on the left arm, with no other complaints and instruction to use an over‑the‑counter anti‑rash cream?

• A. 99202
• B. 99204
• C. 99201
• D. 99203

Answer: (C)

The key idea is choosing the E/M level based on history, exam, and medical decision making for a new patient with a simple problem. Here, a new patient presents with a single, straightforward dermatologic issue (a mild rash) and the plan is simply to use an over-the-counter anti-rash cream with no further workup, no other symptoms, and no additional diagnoses. This setup yields minimal history (one uncomplicated problem), a limited exam focused on the rash, and minimal medical decision making (no tests, no prescriptions beyond education and OTC guidance). That combination fits the lowest level available for a new patient visit, which is designed for straightforward, uncomplicated problems. If the rash required more extensive history or exam, or if there were multiple problems, medications beyond OTC, testing, or referrals, a higher level would be appropriate. Time-based coding could come into play in some scenarios, but the element-based approach here supports the simplest level for a new patient with an uncomplicated issue.

The key idea is choosing the E/M level based on history, exam, and medical decision making for a new patient with a simple problem. Here, a new patient presents with a single, straightforward dermatologic issue (a mild rash) and the plan is simply to use an over-the-counter anti-rash cream with no further workup, no other symptoms, and no additional diagnoses.

This setup yields minimal history (one uncomplicated problem), a limited exam focused on the rash, and minimal medical decision making (no tests, no prescriptions beyond education and OTC guidance). That combination fits the lowest level available for a new patient visit, which is designed for straightforward, uncomplicated problems. If the rash required more extensive history or exam, or if there were multiple problems, medications beyond OTC, testing, or referrals, a higher level would be appropriate. Time-based coding could come into play in some scenarios, but the element-based approach here supports the simplest level for a new patient with an uncomplicated issue.