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Code CPT

  1. Default 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 by AlphaNicole; 09-27-2018 at 07:24 AM.

  2. #2
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    Quote Originally Posted by AlphaNicole View Post
    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.
    EVELYN KIM , MBA, CFE, CPC, CPMA,CRC
    Manager, SIU

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