Coding Corner Answer

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Answer: 99213 Diagnosis: 715.96

This is an established patient outpatient/office visit and should be coded as 99213 because it included:

• An expanded problem-focused history, history of present illness: five elements, review of systems: two systems reviewed, and past family and social history: not addressed;
• Detailed-focused examination: five systems; and
• Straightforward decision making: one stable problem improving, moderate overall risk for prescription drug management, and no diagnostic studies ordered.