What is the appropriate CPT code for an established patient outpatient visit with moderate medical decision-making for a patient with acute bronchitis, chronic cough, and a history of breast cancer?

CPT Code Selection: 99214 is Appropriate

Based on the documentation provided, CPT code 99214 (Established patient outpatient visit, Moderate MDM and/or 30-39 minutes) is the correct billing code for this encounter.

Justification for Moderate Medical Decision Making (MDM)

The encounter clearly meets criteria for moderate complexity MDM based on multiple factors:

Number and Complexity of Problems Addressed

• Multiple chronic conditions managed: The patient has acute bronchitis superimposed on a history of breast cancer with ongoing chemotherapy-related complications (persistent leukopenia and thrombocytopenia), hypertension, hyperlipidemia, anxiety disorder, and OCD 1
• Acute problem with systemic symptoms: The patient presents with 1.5 months of productive cough with purulent sputum, fever, dyspnea on exertion, and profound fatigue despite two prior courses of antibiotics and steroids—indicating treatment failure requiring diagnostic re-evaluation 2
• Immunocompromised status: Recent chemotherapy (last dose February 17,2024) with persistent cytopenias places this patient at higher risk for complications from respiratory infections 2

Amount and Complexity of Data Reviewed/Ordered

• Imaging ordered: Chest x-ray (two views) to rule out pneumonia, which is appropriate given the prolonged symptoms, fever, and dyspnea on exertion 2
• Laboratory testing ordered: CBC to assess current white blood cell status in context of known chemotherapy-related leukopenia, plus ESR and CRP to evaluate for pneumonia 2
• Review of prior treatment failures: Assessment of inadequate response to two antibiotic courses and prednisone requires clinical judgment about alternative diagnoses 2

Risk of Complications and Morbidity

• Prescription drug management: Transition from azithromycin to broader-spectrum Augmentin (amoxicillin-clavulanate) represents moderate risk given the need to cover potential pneumonia organisms 2, 3
• Risk stratification in immunocompromised patient: The combination of persistent symptoms, fever, and immunosuppression from recent chemotherapy elevates the risk of serious complications including pneumonia 2, 4
• Planned follow-up for diagnostic results: The need to review chest x-ray and laboratory results within one week indicates ongoing diagnostic uncertainty requiring close monitoring 1

Key Clinical Decision Points Documented

Appropriate Diagnostic Workup

• The chest x-ray is indicated because the patient has abnormal vital signs (fever documented this morning), prolonged symptoms (>6 weeks), dyspnea on exertion, and failed antibiotic therapy—all suggesting possible pneumonia rather than simple acute bronchitis 2
• CRP and ESR testing align with guideline recommendations for suspected pneumonia, where CRP ≥30 mg/L combined with fever and dyspnea increases pneumonia likelihood 2
• CBC is appropriate given known chemotherapy-related cytopenias and need to assess current immune status 1

Treatment Modification Based on Clinical Reasoning

• The switch to Augmentin demonstrates appropriate escalation from azithromycin to cover broader spectrum organisms, including those causing pneumonia, in a patient with treatment-refractory symptoms 2, 3
• Recognition that routine antibiotics are not indicated for uncomplicated acute bronchitis, but this patient's prolonged course, fever, dyspnea, and immunocompromised status warrant antibiotic therapy 2, 4

Common Pitfalls Avoided

• Not undercoding based on normal physical exam: Despite clear lungs on auscultation, the clinical complexity (immunocompromised status, treatment failures, systemic symptoms) and diagnostic uncertainty justify moderate MDM 2, 1
• Recognizing that time is not the determining factor: While the code includes "30-39 minutes," the MDM complexity is what drives this code selection, not time spent 5
• Appropriate use of diagnostic testing: The chest x-ray is not routine for acute bronchitis but is indicated here due to fever, dyspnea, prolonged symptoms, and immunocompromised status—demonstrating appropriate clinical judgment 2, 4

Why 99213 Would Be Insufficient

A 99213 (low complexity MDM) would not capture:

• The diagnostic complexity of evaluating treatment-refractory respiratory symptoms in an immunocompromised patient 1
• The risk assessment required for a patient with recent chemotherapy and persistent cytopenias 2
• The coordination of multiple diagnostic tests and medication changes with planned short-term follow-up 1

The documentation supports 99214 based on moderate MDM complexity, regardless of time spent during the encounter 5.