Primary Care Coding Alert

Question: A 13-year-old established patient reports to the FP for treatment of his acne. During an expanded problem focused history, the practice's non-physician practitioner (NPP) learns that the patient tried several over-the-counter acne treatments, but nothing worked. The NPP diagnoses camedopapular acne, prescribes a medication regimen and sends the patient home (medical decision making [MDM] was straightforward). What would be the nature of presenting problem (NOPP) and E/M code for this encounter?California SubscriberAnswer: The NOPP in this encounter is most likely self-limited or minor or of low severity, though you might want to double-check with the NPP to be sure. Based on the extent of the history and MDM noted, you should report the following:99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components; a problem focused history; a problem focused examination; straightforward medical decision [...]