AAPC Certified Professional Coder (CPC) — Question 145

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 CPT® coding is reported for this visit?

Answer options

• A. 99385
• B. 99202
• C. 99385-25, 99203
• D. 99385, 99203-25

Correct answer: C

Explanation

The correct coding is 99385-25, 99203 because the visit includes a preventive service along with an additional evaluation and management service for the lesions, necessitating the use of modifier '-25' to indicate that the problem-focused service was distinct and separate from the preventive visit. Options A, B, and D do not accurately reflect the need for both the preventive and the problem-focused services with the appropriate modifier.