The scenario presented was an established patient office visit for follow-up of attention-deficit/hyperactivity disorder (ADHD). This is the chief complaint for the encounter. The diagnoses documented in the assessment and plan include ADHD combined type and poison ivy dermatitis. The International Classification of Diseases, 10th Revision, Clinical Modification codes are F90.2 (ADHD, combined type) and L23.7 (allergic contact dermatitis due to plants, except food). Additionally, the patient was screened for depression (Z13.89, screening for other disorders).

Documentation of the office visit indicates the total face-to-face time of 25 minutes and time of counseling of 20 minutes. This documentation supports reporting the visit based on time spent in counseling and/or coordination of care because more than 50% of the total time was spent in counseling. Because the patient is established, code 99214 is appropriate.

If reporting based on key components of history, examination, and medical decision-making, the documentation supports...

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