For Group C & D conditions in a NEW patient (nerve, disc, and degenerations), which CPT code applies?

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

Answer: (B)

When coding a new patient visit, you choose the level based on how much history you document, how thorough the exam is, and how complex the medical decision making is. For a patient presenting with nerve symptoms and degenerative disc changes, you typically need a broader history that explores onset, progression, radicular or neurological symptoms, red flags, and functional impact. The exam also becomes more comprehensive, including expanded neurological and musculoskeletal assessment to pin down the level of involvement and ruling out other possibilities.

Because this scenario involves more than a minimal workup but does not reach high-risk or highly complex management, the medical decision making is considered low complexity. Put together, that combination—expanded problem-focused history, expanded problem-focused examination, and low complexity medical decision making—best matches this presentation for a new patient.

That’s why this answer is chosen: it reflects the level of documentation and decision making appropriate for a new patient with nerve-related and degenerative spine concerns. It isn’t the level for a straightforward new-patient visit, nor the higher levels that require more extensive data, risk, and management, and it isn’t used for established patients.