An established adolescent patient presents for follow-up of attention-deficit/hyperactivity disorder (ADHD). The patient’s height, weight, blood pressure, and respiratory rate are measured and documented by a medical assistant. The medical assistant also confirms that the patient’s current medications are unchanged from the last encounter and notes that the patient has started 10th grade and is working part-time for a house-painting service. A review of systems completed by the patient is positive for insomnia, fatigue, and a rash.
The physician documents
The physician spent 20 minutes of the 25-minute visit counseling the patient and his mother on management options.
What are the procedure and diagnosis codes for this encounter? What would the procedure code be, based on the time of counseling and/or coordination of care?
See You Code It! Answers: Established Patient Evaluation and Management Visit for the answers!