In the coding scenario presented earlier in this newsletter, a 16-year-old patient presented with a chief complaint of amenorrhea. The physician assessment included

The pediatrician also documented a negative pregnancy test result (Z32.02) and screened for alcohol/substance use (Z13.39) and depression (Z13.31).

The history was comprehensive and the examination detailed. Moderate medical decision-making (MDM) included addressing a new problem requiring further workup and ordering of radiology and laboratory testing, as well as an undiagnosed new problem with an uncertain prognosis. The patient is new because she has not received a face-to-face service from a physician (of the same specialty) in the same group practice in the last 3 years. This supports code 99203. If a comprehensive examination had been performed, code 99204 would be supported by the comprehensive history and examination with moderate-complexity MDM.

Also assigned are procedure codes for the urine pregnancy...

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