A 65-year-old male who never goes to the doctor comes in with bronchitis/cold/flu symptoms. The

A 65-year-old male who never goes to the doctor comes in with bronchitis/cold/flu symptoms. The doctor works him up for bronchitis and meets the key components for E/M code 99213. The doctor feels it is important to do a PSA, but the patient refuses the other components of a preventive visit. How do you code this? Do you use just the E/M Office/Outpatient Visit plus code the PSA, or do you code E/M Office/Outpatient Visit, preventive medicine, and/or PSA test with a modifier?

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CPT Knowledgebase - Jun 17, 2015