What is required to accurately code a visit using 99201?

The correct choice is based on the requirements set forth for coding visits using the CPT code 99201, which is specifically intended for a problem-focused evaluation. To appropriately use this code, the clinician must document a problem-focused examination along with a problem-focused history.

A problem-focused exam focuses on addressing the chief complaint and involves a limited examination of affected body areas or related organ systems. This level of coding reflects a straightforward visit where the patient presents a specific problem that requires a focused approach.

While other options like an expanded HPI or comprehensive history indicate a more in-depth assessment, they exceed the necessary documentation weight for 99201, which does not require such comprehensive elements. The coding guidelines are explicit about the necessity for a problem-focused evaluation to justify the 99201 designation accurately.