For an office visit for a new patient, which code represents detailed history and detailed exam with moderate medical decision-making?

Prepare for the NHA Billing and Coding Specialist exam. Study effectively with flashcards and multiple-choice questions offering explanations and hints. Ensure you're ready for success!

The correct code for an office visit for a new patient that represents a detailed history, detailed examination, and moderate medical decision-making is indeed 99204. In the context of Evaluation and Management (E/M) coding, this code is specifically designated for new patients who require a moderate level of complexity in their care.

When assigning E/M codes, documentation plays a crucial role. A detailed history indicates that the provider has collected extensive information about the patient's medical history, including a review of systems and the patient's social and family history. A detailed exam shows that the provider has conducted an in-depth physical examination to assess the patient’s health status.

Moderate medical decision-making involves a review of the existing problems, the amount of data to be reviewed, and the risk factors associated with the patient's condition. For a patient requiring moderate decision-making, there may be multiple problems, or a new problem that requires additional workup and management.

This combination of detailed history, examination, and moderate complexity in decision-making aligns precisely with the coding characteristics of 99204, thereby making it the appropriate choice for this scenario.

Subscribe

Get the latest from Examzify

You can unsubscribe at any time. Read our privacy policy