Coding

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Coding Scenarios for MDM:

47-year-old Joe presents for an initial visit to colorectal surgeon Dr Heck for evaluation of

painless blood per rectum associated with bowel movements. Dr Heck performs a medically

appropriate history and physical examination and determines the medical decision making to be

low.

Code answer: 99203

A 35-year-old female established patient presents to her physician for follow-up of her stable

type 1 diabetes mellitus. The physician performs a medically appropriate history and physical

and determines the visit meets a low level of medical decision making.

Code answer: 99213

72-year-old established patient Jillian presents for a routine three-month follow-up visit to her

oncologist Dr. Connor for nodular small cleaved-cell lymphoma. Dr. Connor performs a

medically appropriate history and physical exam and determines the medical decision making to

be low.

Code answer: 99213

25-year-old established patient Sam presents to his family physician for follow-up of a clearing

patch of localized contact dermatitis on his left forearm. The physician performs a medically

appropriate history and physical examination and determines the medical decision making to be

straightforward.

Code answer: 99212

3-year-old Emma, who is new to the area, presents with her parents for an initial visit to

pediatrician Dr. Canyon for evaluation of juvenile diabetes mellitus and a past history of

hospitalization times three. Dr. Canyon performs a medically appropriate history and physical

examination and determines the medical decision making to be moderate.

Code answer: 99204

Sample Coding Scenarios for Time:

Sal, a 33-year-old male, and his spouse present to his urologist for an initial visit for counseling

concerning voluntary vasectomy for sterility. The physician spends 25 minutes discussing the

procedure, risks and benefits, and answering questions.

Code answer: 99202

48-year-old Megan presents for a follow-up visit with her pain management physician, Dr

Sanchez, for reassessment and reassurance/counseling for increasing symptoms while on a pain

management treatment program. Dr Sanchez performs a medically appropriate history and

physical examination, and discusses risk factor reduction and importance of compliance with the

treatment program with Megan, total time of the visit is 30 minutes.

Code answer: 99214

59-year-old laborer Carlos presents for an initial visit to his orthopedic surgeon Dr. Grant for

evaluation of degenerative joint disease of the left knee with no prior treatment. Dr. Grant

performs a medically appropriate history and physical examination and discusses risks and

benefits of the treatment options with Jesse. The total time of the visit is 35 minutes.

Code answer: 99203

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Coding Scenarios for MDM: 47-year-old Joe presents for an initial visit to colorectal surgeon Dr Heck for evaluation of painless blood per rectum associated with bowel movements. Dr Heck performs a medically appropriate history and physical examination and determines the medical decision making to be low. Code answer: 99203 A 35-year-old female established patient presents to her physician for follow-up of her stable type 1 diabetes mellitus. The physician performs a medically appropriate history and physical and determines the visit meets a low level of medical decision making. Code answer: 99213 72-year-old established patient Jillian presents for a routine three-month follow-up visit to her oncologist Dr. Connor for nodular small cleaved-cell lymphoma. Dr. Connor performs a medically appropriate history and physical exam and determines the medical decision making to be low. Code answer: 99213 25-year-old established patient Sam presents to his family physician for follow-up of a clearing patch of localized contact dermatitis on his left forearm. The physician performs a medically appropriate history and physical examination and determines the medical decision making to be str ...
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