Assign the appropriate Evaluation and Management code for an office visit for the following exercise. Do not code the diagnosis or the referral to Dr. Andrews.
This is a 15-year-old girl, never seen at this clinic. During a problem-focused history, she states that she noticed a lump on the back of her right wrist yesterday.
Physical Examination: There is a 2-cm freely movable, rubbery, round swelling on the dorsal surface of the right wrist. Distal neurovascular and tendon exam intact. This is not painful to palpation. (The MDM was of straightforward complexity.)
Impression: Ganglion cyst, right wrist.
Treatment: Refer to Dr. Andrews for further treatment.
99201 Hint: Evaluation and Management, Office or Other Outpatient Services