Coding Corner Answer

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Answer: 99213

Diagnosis: 715.96

This is an established outpatient/office visit and should be coded as 99213 because it included:

• Expanded problem-focused history:
  • History of present illness has five elements: location, duration, timing, severity, and context
  • Review of system: one system reviewed—musculoskeletal
  • Past, family, social history: Past medical history
  • Expanded problem-focused examination:
  • Four systems examined: constitutional, musculoskeletal, respiratory, and cardiovascular

• Straightforward decision making:
  • One stable problem improving, moderate overall risk for prescription drug management, and no data were reviewed or ordered