Code CPT

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I am asking for assistance on these question as they have me stuck during practice.


#1 16 year old, new clinic, problem focused history, noticed a lump on her wrist.
P/E: There is a 2cm freely movable, rubbery swelling on the dorsal surface of her right wrist that was notice a day ago. Distal neurovascular and tendon exam intact. This is not painful to palpation. MDM straightforward in complexity. Impression: Ganglion cyst, right wrist.
Treatment: Refer to Dr. Adams for further treatment.
CPT code? 99201

# 2 Clinical Note: Established patient here for routine examination.
Subjective: April is 47 year old female patient who presents today for routine physicial examination
Objective: BP 120/81. Pelvic exam: normal external genitalia. Vagina without discharge except for a scant amount of white dischage that appears normal. Cervix: Multiparous, clear. Bimannual exam is unremarkable. All systems are within normal limits
Assessment: Normal BP...Normal pelvic exam
Plan: Return in 1 year or prn
CPT code? 99396
 
Last edited:

Evelyn Kim

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Local Chapter Officer
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San Antonio, TX
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I am asking for assistance on these question as they have me stuck during practice.


#1 16 year old, new clinic, problem focused history, noticed a lump on her wrist.
P/E: There is a 2cm freely movable, rubbery swelling on the dorsal surface of her right wrist that was notice a day ago. Distal neurovascular and tendon exam intact. This is not painful to palpation. MDM straightforward in complexity. Impression: Ganglion cyst, right wrist.
Treatment: Refer to Dr. Adams for further treatment.
CPT code? 99201

# 2 Clinical Note: Established patient here for routine examination.
Subjective: April is 47 year old female patient who presents today for routine physicial examination
Objective: BP 120/81. Pelvic exam: normal external genitalia. Vagina without discharge except for a scant amount of white dischage that appears normal. Cervix: Multiparous, clear. Bimannual exam is unremarkable. All systems are within normal limits
Assessment: Normal BP...Normal pelvic exam
Plan: Return in 1 year or prn
CPT code? 99396
I would refer you to the E&M level guidelines.
In example #1 this is a new patient, Problem focused history, Problem focused exam, and Straight forward medical decision making equals a level 1 new patient visit.
In example # 2 This appears to be a well woman exam. The documentation supplied does not appear to meet the requirements of 99396. Review the CPT code definition.
 
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