Question

question 17

a 45-year-old established; female patient is seen today at her providers office. she is complaining of severe dizziness and feels like the room is spinning. she has had palpitations on and off for the past 12 months. for the ros, she reports chest tightness and dyspnea but denies any edema or arm pain. she drinks two cups of coffee per day. her sister has wpw (wolff-parkinson-white) syndrome. an extended exam is performed. an ekg is ordered. metabolic panel and complete blood count labs are ordered and drawn. final diagnosis is suspected wpw. to purchase over the counter dramamine for the dizziness. what cpt® code is reported for this visit?

99214
99215
99204
99203

Explanation:

Analyze the patient type and setting

• Patient: 45-year-old established female patient.
• Setting: Provider's office.
• Applicable CPT code range: 99211–99215 (Office or other outpatient visit for the evaluation and management of an established patient).

Determine the level of Medical Decision Making (MDM)

• Number and Complexity of Problems Addressed: Moderate. The patient has multiple problems/symptoms: severe dizziness (suspected vertigo), palpitations on and off for 12 months, chest tightness, and dyspnea, with a family history of Wolff-Parkinson-White (WPW) syndrome. This represents 1 or more chronic illnesses with mild exacerbation, progression, or side effects of treatment, or an undiagnosed new problem with uncertain prognosis (suspected WPW/cardiac etiology).
• Amount and/or Complexity of Data to be Reviewed and Analyzed: Moderate. The provider orders and reviews 3 distinct tests: an EKG, a metabolic panel, and a complete blood count (CBC).
• Risk of Complications and/or Morbidity or Mortality of Patient Management: Moderate. The provider recommends over-the-counter Dramamine, but the overall clinical presentation of cardiac symptoms (palpitations, chest tightness, dyspnea) with suspected WPW represents moderate risk.
• MDM Level: Moderate MDM (requires meeting 2 out of 3 elements at moderate level).

Select the appropriate CPT code

• For an established patient office visit, 99214 requires a moderate level of medical decision making.
• Therefore, the correct CPT code is 99214.

Answer:

• (A) 99214 (Correct answer)
• (B) 99215
• (C) 99204
• (D) 99203