For a NEW patient with Group A & B conditions such as Pain, Spasms, SP/ST, trigger points, fascitis, and facet issues, which CPT code applies?

• A. 99203
• B. 99204
• C. 99202
• D. 99212

Answer: (C)

The key idea here is that evaluating and coding for a new patient hinges on the level of service defined by the history, the exam, and the medical decision making—not simply the number of problems the patient has. For a new patient presenting with musculoskeletal complaints like pain, spasms, trigger points, plantar fasciitis, and facet issues, if the documentation shows a problem-focused history and a focused exam with straightforward medical decision making, this fits the lowest level of new-patient evaluation and management. That level reflects an initial, uncomplicated assessment with a simple plan, which is appropriate when no additional data gathering, testing, or complex management is required.

Higher codes would be chosen only if the chart demonstrates more extensive history and exam, or more complex medical decision making (for example, multiple issues requiring more analysis, testing, or a broader management plan). The established-patient code would not apply here since the patient is new. So, the best match is the lowest new-patient level given straightforward documentation; if the chart showed greater complexity, one would move up to the higher levels accordingly.