A female patient was seen for an office consultation with a

A female patient was seen for an office consultation with a gynecologist by her family practice physician. The patient has been suffering from pelvic pain and in a detailed history, the gynecologist noted the location, severity and duration of her pain. In the review of systems, the patient had positive findings related to her gastrointestinal, genitourinary and endocrine body systems. The physician made note of her medical history. The detailed physical examination centered on her gastrointestinal and genitourinary systems with a complete pelvic exam. The physician ordered lab tests and a pelvic ultrasound. The medical decision making was moderate in complexity.

What is the appropriate CPT code that they physician would report?

Solution

99244 is a correct CPT code

Level 4 Office Consult (99244)

A patient with one chronic illness with a mild exacerbation or two stable chronic illnesses would satisfy the risk requirement for this level of medical decision-making.

Requires two out of three of the following:

1)   Three problem points
2)   Three data points
3)   Moderate risk