Question

a 75 - year - old established patient sees his regular primary care provider for a physical screening prior to joining a group home. he has no new complaints. the patient has an established diagnosis of cerebral palsy and type 2 diabetes and is currently on his meds. a comprehensive history and examination is performed. the provider counsels the patient on the importance of taking his medication and gives him a prescription for refills. blood work was ordered. ppd was done and flu vaccine given. patient already had a vision exam. no abnormal historical facts or finding are noted. what cpt® code is reported?
o 99215
o 99397
o 99214
o 99387

Explanation:

Step1: Identify the service type

The patient is having a physical examination with history - taking, examination, counseling etc. This is an established patient visit.

Step2: Determine the level of service

Based on the information provided, it seems to be a comprehensive history and examination with counseling. For established patients, the appropriate CPT code for a detailed or comprehensive history and examination with medical decision - making is considered. The code 99397 is for established patients, age 65 and over, for a comprehensive history, comprehensive examination, and medical decision - making of moderate complexity.

Answer:

99397