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CPT code: 99231, Diagnosis: 714.0

This visit includes the following to make it a level-one subsequent hospital visit:

Problem-focused history:

Brief history of present illness: location, modifying factor;
Problem-pertinent review of systems: musculoskeletal; and
Past family social history was not addressed, nor is it necessary in determining subsequent hospital visit levels.

Detailed examination:

Five systems: constitutional, respiratory, cardiovascular, gastrointestinal, and musculoskeletal.

Straightforward decision making:

Rheumatoid arthritis is stable; and
Recovering from surgical procedure.

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