Answer and Analysis

You see an established office patient with stable HTN. You make no changes to medications and order a BMP, lipid panel for the next visit in 6 months. Total time spent is 15 minutes.

Correct Answer: 99213

For these encounters, the level of care may be selected based on time or based on the MDM. If coding based on time, this visit would only qualify for the 99212 visit. On the other hand, this encounter requires low complexity MDM based on the problems addressed (one stable chronic illness) and the data reviewed (ordering of two unique tests) and low risk as outlined below. Low complexity MDM points us toward the 99213 level of care, which is the correct code for this encounter.

Requires two out of three dimensions to qualify