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CASE STUDY
A new patient comes in with complaints of diarrhea and watery stool the previous night, as well as nausea, vomiting, and lower abdominal pain. The physician provides a detailed history and examination, with moderate medical decision making. The correct level of E/M visit that should be billed is:

Answer: c

New patient visits require all three, History, Exam and Medical Decision Making. All three key components/elements were documented to the required level for 99203. Detailed history and examination, with moderate medical decision making. Even though the medical decision making actually met the required level for code 99204, the final determination is based on the lowest documented element. The history and exam would have had to be comprehensive to make the selected code 99204.

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