This encounter is coded as 99203, because it included:
- History—The history of present illness was extended. The review of systems was complete, and the past medical, family and social were documented. This makes the history comprehensive.
- Examination—Expanded detailed.
- Medical decision making—The diagnosis was a new problem with no additional workup planned; review and summarization of old records (labs from another physician); acute uncomplicated illness or injury. The medical decision making was of low complexity.
ICD-10: M79.1 Leg muscle pain, noninflammatory.
For questions or additional information on coding and documentation guidelines, contact Melesia Tillman, CPC-I, CPC, CRHC, CHA, at firstname.lastname@example.org or 404-633-3777 x820.