Character Pictures

HCR/220 - CLAIMS PREPARATION I: CLEAN BILLS OF HEALTH (AXIA)

Initial consultation is performed for a 78-year-old woman with unexplained weight loss, abdominal pain, and rectal bleeding. A comprehensive history and examination is performed.

99201-99205 are the codes I would choose. The patient’s history, examination and the medical decision making were all marked with a Y for yes in the comprehensive area. Comprehensive means that the complaint was determined; the patient’s history was taken and talked about in depth. Their complete past, family and social history were all taken.

A 30-year-old patient presents complaining of flu-like symptoms characterized by unremitting cough, sinus pain, and thick nasal discharge. An examination reveals bronchitis and sinus infection. The patient is prescribed a 5-day course of Zithromax.

99202 is the code I would choose. The patient’s problem was expanded and determined. The examination determined the problem and the medical decision making was straight forward. The number of key components required is 3 and the patient CPT codes met all three.

Established patient on Lithium presents for routine blood work to monitor therapeutic levels and kidney function. A nurse reviews the results and advises the patient that tests are normal, and no change in dosage is indicated.

99211 is the code I would use because the patient is an established patient and established patient codes are 99211 through 99215. The reason being for the code to be 99211 is because the nurse is the one who examined the patient.

A 62-year-old diabetic female presents for check-up and dressing change of wound on left foot. An examination reveals the wound is healing. The nurse applied new dressing and patient will return for a check-up in one week.

99214 is the code I would choose. The patient’s history, examination and medical decision making is all minimal. The number of key components required is two and the patient follows under these two...