CPT code: 99231, Diagnosis: 714.0
This visit includes the following to make it a level-one subsequent hospital visit:
- 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.
- Five systems: constitutional, respiratory, cardiovascular, gastrointestinal, and musculoskeletal.
Straightforward decision making:
- Rheumatoid arthritis is stable; and
- Recovering from surgical procedure.