a 50 year old new female patient has had a sore throat and head congestion for five days. the physician performs an expanded problem-focused history and examination and straightfoward medical decision. What is the correct code for this service?
To determine the correct code for the service provided by the physician, we need to consult the Current Procedural Terminology (CPT) codes. In this case, the relevant CPT code would be for an Evaluation and Management (E/M) service.
The level of E/M service is determined based on three key components, i.e., history, examination, and medical decision making. Each component has specific requirements and documentation criteria that need to be met.
1. History: The expanded problem-focused history signifies that the physician collected and documented a limited amount of information related to the patient's current illness or symptoms.
2. Examination: There is no specific information provided regarding the examination carried out by the physician. Without that information, we cannot accurately determine the level of the examination component.
3. Medical Decision Making (MDM): Straightforward medical decision making implies that the physician made straightforward decisions regarding the management options for the patient's condition. The MDM criteria include factors such as the number and complexity of problems addressed, data reviewed, and risk of complications or morbidity.
Given the information provided, if we assume that the examination component meets the requirements for an expanded problem-focused examination, we can use the MDM component to determine the appropriate E/M code.
Based on the level of medical decision making being straightforward, the appropriate E/M code would be 99202. However, it's important to note that without additional information about the examination component, we cannot be certain of the correct code selection. It is crucial to consult the complete documentation and relevant guidelines to accurately assign the appropriate code.