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Case Study
New patient, a 25-year old Female, who had a tray fall on right wrist at work today, comes to the office. She has persistent pain exacerbated with moving the wrist and hand. Describes pain as very severe. Right wrist is swollen and sore to touch. Her past medical history is noncontributory and she has NKA (no known allergies). Provider performed an expanded problem focused examination. An x-ray was ordered and showed no acute fractures. Dx: right wrist sprain. Patient was placed in padded splint and given prescription for Darvocet. She was asked to return in one week. The level of E/M that should be billed is:

Answer: b. 99202

The service falls into the code range 99201 ­ 00295 because she is a NEW outpatient. The history is EPF because there are four or more elements documented in the HPI, including Location, Quality, Severity, Duration, and Modifying Factors. The Review of Systems (ROS) was EPF and there was a Detailed PFSH documented. You were given the fact that the Examination was EPF, and should have been able to determine that the Medical-Decision-Making was Low.

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