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A 20-year-old female is being seen for the first time by a primary care physician to have a yearly physical. During the examination for the physical, the provider discovers non-inflammed lesions on her legs and arms. The physician performs a complete physical and additional separate documentation for the treatment of the lesions on the bilateral upper and lower extremities. The provider has the patient buy an over-the-counter ointment and will continue to watch them. What CPTcoding is reported for this visit?
Correct Answer: D
CPT code 99385 is used for initial comprehensive preventive medicine evaluation and management of an individual, including a detailed history and examination, and anticipatory guidance. Since additional documentation and treatment for non-inflamed lesions are provided, an additional E/M service code 99203 with modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day) is appropriate to indicate both services were rendered. References: CPT Professional Edition (current year), AMA.