Evaluation and Management Coding Based on Time

The Coding Challenge: Evaluation and Management Coding Based on time
Qualified clinical staff is taking the patient’s vitals.

The Coding Challenge

Question: An established 44-year-old male is seen at his physician’s office today for a new 3-cm lump on the left arm. The physician spends 5 minutes reviewing the patient’s chart while other qualified clinical staff takes the patient’s vitals. The physician then spends 15 minutes updating the patient’s history and performing a brief examination of the patient’s arm. The patient states the lump is not painful nor experiences any other symptoms. The physician determines that the lump is a non-cancerous lipoma and requires no treatment. The patient leaves the office, and the physician finishes documenting about the visit in the patient’s record. Total time spent related to the visit on the day of the encounter, including both face-to-face and non-face-to-face time with the patient, was 25 minutes. Based on the time spent, what CPT code is reported for the visit?

A. 99203
B. 99213
C. 99212
D. 99202


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