CPT Knowledgebase - Dec 4, 2025
A 55-year-old female presents to the office as a new patient with chronic fatigue, unexplained weight loss, and muscle weakness that has been ongoing for several months. The patient has a history of hypertension and diabetes and a family history of heart disease. The physician reviews the patient's medical history, family history, and social history. The physician documents the patient's ongoing fatigue, weight loss, and muscle weakness, as well as additional associated symptoms of shortness of breath. The physician conducts an examination and finds evidence of muscle wasting, elevated blood pressure, and abnormal heart sounds on auscultation. For clinical decision-making based on the patient's symptoms and examination findings, the physician is concerned about potential underlying serious conditions (eg, heart failure, thyroid disorder, cancer) and orders a range of tests, including laboratory tests (thyroid function, complete blood count, and basic metabolic panel) and imaging (chest X ray and echocardiogram). In addition, the physician refers the patient to a cardiologist for further evaluation. What would be the appropriate E/M code to report for this scenario?To view the Official AMA answer and 1000s more like this:
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