CPT Knowledgebase - Oct 28, 2022

Question: A 17-year-old male presents with acneiform papules on his chin for 1 month. The patient had clear skin prior to starting football practice. The papules are under the area covered by his chin strap. The patient is diagnosed with acne due to physical occlusion from the chin strap. A prescription for topical benzoyl peroxide 5%/clindamycin 1% gel is provided. Potential side effects of prescribed medications are addressed, and skin care is discussed. The patient is reassured that the acne will likely resolve when the football season is over. What evaluation and management (E/M) code would be appropriate to report for this service?

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