A 45-year-old established female with dizziness and vertigo; EKG ordered; labs drawn; final diagnosis suspected benign paroxysmal positional vertigo. What CPT code is reported for the established patient visit?

A 45-year-old established female with dizziness and vertigo; EKG ordered; labs drawn; final diagnosis suspected benign paroxysmal positional vertigo. What CPT code is reported for the established patient visit?

• A. 99214
• B. 99215
• C. 99203
• D. 99204

Answer: (A)

In established patients, the code level reflects how much history you obtain, how thorough your exam is, and how complex the medical decision making is. Here, dizziness with vertigo prompts a detailed history—characteristics of the dizziness, onset, duration, triggers, associated symptoms, and prior episodes—and a thorough vestibular/neurological exam, which may include maneuvers to assess BPPV. Ordering an EKG and labs adds data to review and plan, contributing to moderate complexity in decision making. The overall documentation fits a detailed history, a detailed or extended exam, and low-to-moderate medical decision making, which corresponds to the established-patient level 99214. Higher levels (99215) would require high complexity MDM or more than one significant problem, which isn’t indicated here, and the new-patient codes (99203/99204) are for patients who are new, not established.

In established patients, the code level reflects how much history you obtain, how thorough your exam is, and how complex the medical decision making is. Here, dizziness with vertigo prompts a detailed history—characteristics of the dizziness, onset, duration, triggers, associated symptoms, and prior episodes—and a thorough vestibular/neurological exam, which may include maneuvers to assess BPPV. Ordering an EKG and labs adds data to review and plan, contributing to moderate complexity in decision making. The overall documentation fits a detailed history, a detailed or extended exam, and low-to-moderate medical decision making, which corresponds to the established-patient level 99214. Higher levels (99215) would require high complexity MDM or more than one significant problem, which isn’t indicated here, and the new-patient codes (99203/99204) are for patients who are new, not established.