A new patient was seen in the office complaining of ear pain, headache and a mild fever. The physician performed a problem-focused history assessment and an expanded problem-focused examination on the patient. The physician diagnosed the patient with an acute inner ear infection. This medical diagnosis was considered to be of low complexity. What is the correct E&M code for the service?
Explanation
Answer: B - The correct E&M service is 99202. The patient was new so the codes: 99212 and 99211 would be inappropriate. Code 99201, for a new patient, requires a problem-focused history assessment, problem-focused examination, and a straightforward MDM, but in this case, the examination and MDM levels are higher, allowing us to code for a higher level of service. The correct E&M code for this case is 99202.
