For a COVID‑19 return‑to‑work visit (single resolved viral illness) with 2 min HPI, 5 min exam, 3 min assessment, 2 min documentation (total 12 min), what CPT code is appropriate based on time and based on MDM? For a 54‑year‑old female six‑month follow‑up of diabetes mellitus, chronic obstructive pulmonary disease, and hypertension with labs reviewed and a total visit time of 20 min (moderate‑complexity MDM), what CPT code is appropriate based on time and based on MDM?

CPT Coding for COVID-19 Return-to-Work Visit and Multi-Condition Follow-Up

Case 1: COVID-19 Return-to-Work Visit

For a straightforward return-to-work visit after resolved COVID-19 with 12 minutes total time, use CPT 99212 based on either time or medical decision-making (MDM).

Time-Based Coding

• Total visit time of 12 minutes falls within the 10-19 minute range for CPT 99212 1
• Time includes face-to-face activities: HPI review (2 min), examination (5 min), assessment (3 min), and documentation (2 min) 1

MDM-Based Coding: Straightforward Complexity

Number and Complexity of Problems: Straightforward

• Single self-limited problem (resolved viral illness) with no ongoing management required 1, 2
• Patient is asymptomatic with negative test confirming resolution 1

Amount/Complexity of Data: Minimal

• Review of single negative COVID-19 test result from outside laboratory 1
• No additional diagnostic workup or consultation required 2

Risk of Complications: Minimal

• No treatment initiated; patient fully recovered 1, 2
• Return-to-work clearance carries no procedural or management risk 1

Level of MDM: Straightforward (requires 2 of 3 elements at straightforward level)

• All three elements meet straightforward criteria 1

CPT Code: 99212 (based on either 12 minutes time OR straightforward MDM)

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Case 2: Six-Month Follow-Up for Diabetes, COPD, and Hypertension

For a 54-year-old with stable chronic conditions requiring medication management and laboratory review over 20 minutes, use CPT 99214 based on time; CPT 99213 based on MDM.

Time-Based Coding

• Total visit time of 20 minutes falls within the 20-29 minute range for CPT 99214 3, 1
• CPT Code Based on Time: 99214 3

MDM-Based Coding: Low to Moderate Complexity

Number and Complexity of Problems: Low to Moderate

• Three stable chronic conditions (diabetes mellitus, COPD, hypertension) under active management 4, 5, 6
• Patient compliant with medications and diet for several years indicates stable disease 4, 7
• Wheezing and rales noted on exam suggest COPD monitoring required but no acute exacerbation 6
• These represent stable chronic illnesses rather than acute exacerbations, placing this at low complexity 1, 6

Amount/Complexity of Data: Limited

• Review of CBC, Hemoglobin A1C, full chemistry panel with lipid profile represents multiple unique tests 4, 7
• Laboratory data reviewed and analyzed for three chronic conditions 4, 7
• This meets limited data complexity (review of tests and consideration of history from external source) 1

Risk of Complications: Low to Moderate

• Prescription drug management for multiple chronic conditions (insulin, metformin, metoprolol) 4, 7
• Diabetes with COPD and hypertension represents moderate risk given potential for complications if uncontrolled 4, 5, 6, 7
• However, stable disease with good compliance reduces immediate risk 4, 7
• Slight dehydration noted requires monitoring but no acute intervention 1

Level of MDM: Low Complexity (requires 2 of 3 elements)

• Problems: Low (stable chronic conditions) 4, 6
• Data: Limited (multiple test review) 1
• Risk: Low to Moderate (prescription management of chronic conditions) 4, 7
• Two of three elements at low level = Low complexity MDM 1

CPT Code Based on MDM: 99213 1

Rationale for MDM Discrepancy

While the patient has three chronic conditions requiring ongoing management, their stability over several years with excellent compliance and absence of acute complications places the complexity at low rather than moderate 4, 6, 7. The physical findings (wheezing, slight dehydration) require monitoring but do not indicate acute deterioration requiring intensive management 1, 6. The time-based code (99214) is higher than the MDM-based code (99213) in this scenario 3, 1.

Common Pitfalls to Avoid

• Do not automatically assign moderate complexity simply because multiple chronic conditions exist; stability and compliance reduce complexity 1, 4
• In patients with diabetes and COPD, absence of acute exacerbation or poor control keeps MDM at low level despite multiple comorbidities 4, 6, 7
• When time-based and MDM-based codes differ, select the code that provides appropriate reimbursement based on documentation supporting either method 3, 1