It is anticipated that the initial discussion post should be in the range of 250-300 words. Substantive content is imperative for all posts. All discussion prompt elements for the topic must be addressed. Please proofread your response carefully for grammar and spelling. All posts should be supported by a minimum of one scholarly resource, ideally within the last 5 years. Journals and websites must be cited appropriately. Citations and references must adhere to APA format.

Initial Discussion Question/Prompt

Consider the following questions in your initial discussion post:

  • Review the SOAP note. For purposes of the assignment, the patient is a ‘new patient’ in the practice.

Initial Post

Determine what CPT E&M Code to utilize for this ‘new patient’ encounter using the medical decision-making (complexity) approach.

Provide justification for the code you assigned by including the following information in your discussion:

  1. The level of medical complexity encompassed by including the number of points for the diagnoses/management options and the amount/complexity of data reviewed; then identify the level of risk for complications, morbidity, mortality.

SOAP note:

Chief Complaint:

“I don’t know how much longer I can go on like this. I’ve been down in the dumps for years and it isn’t getting any better.”

History of Present Illness:

75-year-old white male present to clinic with above complaint. Lost his first, the “love of his life” wife 19 years ago. Remarried 2 years after her death and states he probably married again too soon reporting his current wife is difficult. He describes an instance, when he was at work, the second wife would not let his son, daughter-in-law and new grandbaby into his house to visit until he got home from work. The second wife also insisted that he no longer visit with his deceased wife’s family telling him ‘when you married me, you divorced that whole family’. Conversations with his wife about his concerns resulted in only short-term changes in her approaches and behaviors. Now his wife insists they sell the house he has lived in for 46 years. He reports that his memory and ability to make simple decisions have been deteriorating significantly over the last several months. His wife suggested he probably has Alzheimer’s and should go see his primary care provider about his memory issues. He reports that he engages with modest exercise daily, eats well but is waking up numerous times at night and is usually “up for good” by 5am. He blames his disrupted sleep pattern on his feeling of fatigue starting around 9am. He reports all these circumstances as contributing to his increased depression and his desire to “give up the fight”.


reports usual childhood illnesses inclusive of measles, mumps and chickenpox

traumatic injury, likely secondary to ‘blast’ effect, sustained during the bombing of Pearl Harbor where he was stationed as a cook; he suffered a hearing loss for six months after the bombing and was diagnosed at 54 with a rare eyes disorder resulting in poor peripheral vision that is thought to be secondary to this trauma

Family Hx:

Father died at 67 secondary to colon cancer; mother died at 24 secondary to influenza during an epidemic (he was 2 years old at that time)

No know family history of depression or other mental illness

Social Hx:

HS graduate, married to HS sweetheart for 27 years then widowed

Current marriage of 17 years

Retired after 25-year banking career

Attends Catholic mass regularly

Drinks 1-2 beers several times a week, denies episode of intoxication; never smoked or used illicit drugs

Drinks hot tea, reporting coffee causes too much GI distress

Never driven a motor vehicle secondary to poor peripheral vision


Denies HA, body aches, dizziness, fainting spells, tinnitus, ear pain, ear discharge, nasal congestion, diarrhea, constipation, change in appetite skin abnormalities, or genitourinary symptoms

Denies periods of extreme irritability or elation associated with periods of sadness; denies feeling more depressed during the winter months than other seasons

Reports fatigued most of the time, often feels stiffness in his neck and shoulders

Denies homicidal ideations, hallucinations, paranoia or delusions

Reports suicidal thoughts, has a 22-caliber rifle at home and has considered using to end his life


Reports – poor sleep maintenance, loss of pleasure, he feels as though he remarried too soon, he is experiencing fatigue, he is experiencing memory disturbances, eating well, no problems maintaining exercise regimen, is having suicidal ideations


No routine medications



Physical Examination:

Constitutional – BP 118/73, P 83, RR 16, T 98.8, Ht 71 in, Wt 174 lbs, BMI 24

Integument – skin, hair and nails unremarkable

HEENT – PERRLA, EOMs intact, nares patent without discharge noted, TMs gray and shiny bilateral, numerous silver amalgams noted

Neck – supple without adenopathy, no thyromegaly

Lungs – CTA

Heart – RRR without murmur/gallop

Abdomen – soft, non-distended, active bowel sounds, non-tender, no organomegaly

Genitalia/Rectum – deferred

Musculoskeletal – no gross abnormalities or major limitations of ROM noted

Neurologic – CNs II-XII intact, finger-to-nose test negative, DTRs 2+ and equal bilateral, sensory capacity intact upper and lower extremities intact bilateral

Mental status – PHQ 9 score is 19

Diagnostics – Na 138 meq/L, K 4.2 meq/L, Cl 102 meq/L, HCO3 27 meq/L, Bun 11 mg/dL, Cr 0.9 mg/dL, fasting Glu 106 mg/dL, Ca 9.5 mg/dL, Mg 1.8 mg/dL, AST 34 IU/L, ALT 42 IU/L, GGT 38 IU/L, Alb 4.4 g/dL,

TSH 2.8, Vit B12 98 pg/mL, Folic acid 333 ng/mL, PSA 4.9 ng/mL, Hgb 14.3 g/dL, HCT 41.4 %

Urine dipstick – 5.8 pH, SG 1.016, all other parameters negative


1. F32.1 Major depressive disorder, single episode, moderate

2. R45.851 Suicidal ideations/thoughts

3. R73.03 Prediabetes

4. E53.9 Vitamin B deficiency


1. Major depressive disorder

a. Diagnostic – none

b. Therapeutic – citalopram 20mg take 1 by mouth daily dispense #30 with 2 refills

c. Educational – effects of citalopram may not be fully evident for up to 3 or 4 weeks; if you note fatigue exacerbated from the citalopram take it at bedtime; RTC in 1 month for follow up

d. Consultation/Collaboration – none

2. Suicidal ideations/thoughts

a. Diagnostic – none

b. Therapeutic – same as diagnosis #1

c. Educational – same as diagnosis #1; educate on the potential negative impact of his current intake of beer – educate on how to safely reduce this consumption and to avoid abrupt cessation; educate on need to remove the 22-caliber rifle from his home; provide information on suicide hot lines

d. Consultation/Collaboration – referral for counseling

3. Prediabetes

a. Diagnostic – none

b. Therapeutic – none

c. Educational – nutrition education aimed at making dietary lifestyle choices of low glycemic index foods (<55 GI) that aid in development and maintenance of stable insulin and glucose levels

d. Consultation/Collaboration – none

4. Vitamin B deficiency

a. Diagnostic – none

b. Therapeutic – hydroxocobalamin 1000 mcg IM during this OV; start on 2mg oral B-12 daily; recheck Vitamin B-12 level in 2 to 3 months

c. Educational – nutrition education on foods high in B-12

d. Consultation/Collaboration – none



On January 1, 2021, changes were implemented to the E/M codes for evaluation and management of patients in outpatient settings as well as to the CPT codes for current procedural terminology. With this change, providers have the flexibility to focus their coding on the medical decision-making process and report the duration of the encounter, rather than incorporating the evaluation and history criteria. To simplify the process of documenting office visits, the process was changed (The Centers for Medicare & Medicaid Services, 2021).

This patient is a new patient who presents for the establishment of care and to manage acute and chronic problems.

CPT E&M Code: 99205

Diagnosis/Management Options

  • The chronic problem ( Depression) getting worsening =2
  • New Problem ( suicidal ideation with plan) Additional Workup (referral) – 1 = 4 points
  • New Problem ( Vitamin B deficiency) No Additional Workup – max 1 = 3 points
  • Total Points = 9
  • Greater than 4 points = Extensive

Amount/Complexity of Data Reviewed =

  • Review Labs = 1 point
  • Total Points = 1

Risk of Complications, Morbidity, or Mortality

  • High – Threat of suicide with plan and thoughts puts this patient at a high level.

Due to the above reasons, the medical decision would be considered to be of high complexity. A chronic condition that has progressed due to suicidal thoughts, resulting in a threat to the patient’s life. An increased risk of suicide is deemed to be a “high” level of Medical Decision Making by the American Medical Association (2021).


American Medical Association. 2021. CPT Evaluation and Management (E/M).…

The Centers for Medicare & Medicaid Services. (2021). Evaluation and Management Services Guide.…


CPT E&M Codes: 99205 Office Visit, New patient, Level 5

Rationale for the above code:

There are three categories of Medical Decision Making which are Diagnoses/Management options, amount/complexity of data reviewed and risk of complications, morbidity or mortality. American Medical Association (AMA): CPT Evaluation and Management (E/M) Office or Other Outpatient (99202-99215) and Prolonged Services (99354, 99355, 99417) Code and Guideline Changes, 2021):

# of diagnoses/Management options

  • New Problem No Additional Work up = 3 points
  • New problem, additional work up plan = 4 points
  • Total Points = 7points
  • Greater than 4 points Extensive

This is a new patient with prediabetes, Vitamin B12 deficiency, depression with suicidal ideation. A total of four points, which qualifies as “high” complexity in the diagnosis and management component.

Amount/ complexity of data reviewed

  • Review labs = 1 point
  • Total point = 1 point
  • 0-1 point = minimum

The review of laboratory test of fasting glucose and vitamin B12 results

Risk of complication, morbidity or Mortality

Risk level =high

Risk of complication is high due to a psychiatric illness with potential threats to self. He has a plan and the means ( using a rifle gun)

Per American Academy of Professional coder (AAPC) the American medical Association developed new guidelines and code descriptors for office and outpatient E/M codes which took effect last January 1 ,2021. In the 2021 MDM guidelines includes establishing diagnoses, assessing the status of a condition and/or selecting a management option.

The three elements define MDM for office/outpatient visits in 2021 are:

  • The number and complexity of the problem or problems the provider addresses during the E/M encounter.
  • The amount and/or complexity of data to be reviewed and analyzed. The 2021 guidelines list three categories for data: (1) tests, documents, orders, or independent historians, (2) independent test interpretation, and (3) discussion of management or test interpretation with external providers or appropriate sources. The latter term refers to non-healthcare, non-family sources involved in patient management, like a parole officer or case manager.
  • The risk of complications and/or morbidity or mortality of patient management decisions made at the visit. The 2021 guidelines make it clear that options considered, but not selected, are still a factor for this element, specifically after “shared” MDM with the patient, family, or both. Examples include deciding against hospitalization for a psychiatric patient with sufficient support for outpatient care or choosing palliative care for a patient with advanced dementia and an acute condition.


AAPC. (2021, January 15). 2021 E/M coding changes. AAPC.,decision%20making%20of%20low%20complexity.…


CPT E & M Code: 99205

This is a new patient for the office with 4 diagnosis noted in the encounter.

Number of Diagnosis/Management options:

Vitamin B deficiency – 3 points

Suicidal Ideation with plan (gun) – 4 points

Total Points: 7 points which is considered extensive

Time spent/complexity of Data Reviewed:

Clinical Labs reviewed – 1 point

Total points 1

Risk of complications, Morbidity, or Mortality

Suicidal ideation with a plan – High

The patient will be followed up in 1 month for the Vitamin B Deficiency with labs again. Also follow up for Depression and Suicidal Ideation. We also took time reviewing and interpreting the labs for this patient (American Medical Association, 2021)

According to the American Medical Association (2021), a potential risk of suicide constitutes a “high” level of Medical Decision Making. This is a chronic illness with progression that is requiring additional supportive care but not hospitalization at this time. (American Medical Association, 2021).

While not coding by time, if it was to be coded that way, it still would be high due to the amount of time counseling and educating the patient regarding his suicidal ideation and plan. He needs to be counseled to get rid of the gun altogether and not just place it in a locked cabinet.


American Academy of Family Physicians. (n.d.). Coding for Evaluation and Management Services. Retrieved May 15, 2021, from… (Links to an external site.)

American Medical Association. 2021. CPT Evaluation and Management (E/M). Retrieved May 15, 2021, from… (Links to an external site.)


New coding changes are effective for 2021. These changes apply to the E/M codes for evaluation and management in outpatient settings and to the CPT codes for current procedural terminology. The changes were made to eliminate the exam and history coding criteria and provide the provider the ability to focus the coding based on the medical decision-making (MDM) process to code or coding based on the total time spent on the encounter. It was changed to make the process simpler to code office visits (Adamson & Church, 2021).

A table can help the provider use the medical decision-making process to determine the correct E/M billing code to use. Three categories are involved in the medical decision-making process and include diagnoses/management options, the amount/complexity of data reviewed, and the risk of complications, morbidity, or mortality. The following charts can be used to help determine the codes to use based upon these three categories (American Medical Association (AMA): CPT Evaluation and Management (E/M) Office or Other Outpatient (99202-99215) and Prolonged Services (99354, 99355, 99417) Code and Guideline Changes, 2021):

When using these references for the current patient info given, the following is my assessment of the E/M coding with the following points:

  • Number of Diagnosis/Management Options =
    • New Problem No Additional Work up – max 1 = 3 points
    • New Problem Additional Work up (referral) – 1 = 4 points
    • Total Points = 7
    • Greater than 4 points = Extensive
  • Amount/Complexity of Data Reviewed =
    • Clinical Lab Test Reviewed = 1 point
    • No info that records were reviewed etc. – no other points.
    • Total Points = 1
    • Total Points 1 = Minimal or None
  • Risk of Complications, Morbidity, or Mortality
    • High – Threat of Life or Body = Suicide
    • Has plan
    • Has suicidality with plan and thoughts (using a gun)
    • = High

The use of the above coding based upon the scoring system requires two elements under the same code to be present to code for that service (American Medical Association (AMA): CPT Evaluation and Management (E/M) Office or Other Outpatient (99202-99215) and Prolonged Services (99354, 99355, 99417) Code and Guideline Changes, 2021). Based upon this scoring system, the charts provided, and the information provided about the patient, I would code this visit as an: 99205 based upon the two items that fall in this category which are:

  • Number and complexity of problems addressed – Suicidal ideation – Risk to life – High
  • Risks of Complication, Morbidity, or Mortality – Suicidal ideation – Risk to life – High


Adamson, M., & Church, S. (2021). E/M changes for 2021: The beginning, not the end. Family Practice Management, 28(1), 8-10. doi:

American Medical Association (AMA): CPT Evaluation and Management (E/M) Office or Other Outpatient (99202-99215) and Prolonged Services (99354, 99355, 99417) Code and Guideline Changes. (2021). Retrieved May 2021, from American Medical Association (AMA):

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