Question

plan: a repeat of the mri will be obtained. she will return for reassessment following this study. likely begin anothe have also recommended physical therapy. further recommendations are pending her mri.

99205
99202
99204
99203

Explanation:

Analyze the clinical documentation and MDM elements

The documentation outlines a plan: "A repeat of the MRI will be obtained. She will return for reassessment following this study. Likely begin another [course of treatment/therapy]... have also recommended physical therapy. Further recommendations are pending her MRI."

• Number and Complexity of Problems Addressed: The patient has a condition requiring a repeat MRI, physical therapy, and reassessment, representing a moderate level of complexity (e.g., an undiagnosed new problem with uncertain prognosis or an acute/chronic illness with systemic symptoms/moderate severity).
• Amount and/or Complexity of Data to be Reviewed: Ordering a unique test (MRI) and recommending physical therapy represents a moderate level of data/ordering.
• Risk of Complications and/or Morbidity or Mortality of Patient Management: Ordering an MRI and physical therapy represents a moderate risk of patient management.

Determine the Medical Decision Making (MDM) level

• Two out of three MDM elements (Problems, Data, Risk) must meet or exceed the requirements for a given level.
• Here, the complexity of problems addressed is moderate, the data reviewed/ordered is moderate (ordering an MRI), and the risk of patient management is moderate (prescription drug management or physical therapy/imaging decisions).
• Moderate MDM corresponds to a Level 4 Evaluation and Management (E/M) service.

Select the appropriate CPT code

• The codes listed (99202, 99203, 99204, 99205) represent E/M services for a new patient in an office or other outpatient setting.
• Level 4 new patient office visit is represented by CPT code 99204 (which requires moderate MDM).

Answer:

• 99205
• 99202
• 99204 (Correct answer)
• 99203