CPT code: 99214
History: The history of present illness was extended. The review of system was extended (six systems were reviewed) and two of the three elements for past family social history were documented. This makes the history level detailed.
Examination: There were four systems examined. This makes the exam expanded problem focused.
Medical decision-making: The number of the diagnosis was for an established problem that was stable, which is minimal. The amount of data was limited. The level of risk was moderate for prescription drug management. This makes the medical decision making low complexity.
Please note: The documentation of the history, exam, and medical decision-making would normally make this a level-three visit (99213). Because time and the discussion were documented and more than 50% of the visit was spent with the patient face to face, time is the key factor in determining the level of this visit. CPT states that an established patient level-four visit is typically 25 minutes long; this visit was 30 minutes long and qualifies to be coded as a level four (99214).