This encounter is a problem-oriented office visit for an established patient. The correct code is determined by the level of Medical Decision Making (MDM). The MDM is moderate, based on meeting two of the three elements as defined by the 2021 E/M guidelines:

1. Number and Complexity of Problems Addressed: Management of three stable chronic illnesses (Hypokalemia, Hypertension, Esophageal Reflux) is considered a Moderate level.

2. Amount and/or Complexity of Data: Review of previously ordered labs is Limited.

3. Risk of Complications from Patient Management: Prescription drug management (refilling Lisinopril and Potassium) is a Moderate risk.

Since two elements (Problems and Risk) are at the moderate level, the overall MDM is moderate, supporting code 99214.

A. 99212: This code represents a low level of MDM. The management of three chronic conditions with prescription drug management exceeds the complexity for this code.

B. 99396: This is a preventive medicine code for patients aged 40-64. The patient is 65, making this code incorrect based on age.

C. 99397: This is a preventive medicine code. The documented purpose of the visit is a problem-oriented follow-up for chronic conditions, not a comprehensive preventive examination.

1. American Medical Association. CPT® 2023 Professional Edition. Chicago

IL: AMA

2022. Section: "Evaluation and Management (E/M) Services Guidelines

" subsection "Levels of Medical Decision Making (MDM)

" and code descriptors for 99214 and 99397. The guidelines clearly distinguish between problem-oriented visits (99202-99215) and preventive medicine services (99381-99397).

2. American Medical Association. "CPT® Evaluation and Management (E/M) Office or Other Outpatient and Prolonged Services Code and Guideline Changes." 2021. Page 10

"Table 2 – CPT E/M Office Revisions Level of Medical Decision Making (MDM)." This official document specifies that "2 or more stable chronic illnesses" falls under Moderate Number and Complexity of Problems

and "Prescription drug management" falls under Moderate Risk.

3. AAPC. "2021 E/M Guideline Changes for Office and Other Outpatient Services." AAPC Knowledge Center. This official vendor documentation explains that the final MDM level is determined by the highest two of the three elements (Problems

Data

Risk).