Which CPT code is used for a straightforward re-exam?

• A. 99212
• B. 99213
• C. 99214
• D. 99215

Answer: (A)

In evaluation and management coding, the level of service is determined by how complex the history, exam, and medical decision making are. A re-exam is used to reassess an established patient to see how treatment is working and to adjust the plan.

For a straightforward re-exam, the situation is simple: the problem is uncomplicated, data to review are minimal, and the risk is low. In this case, you select the lowest level of established-patient visit, which reflects straightforward medical decision making and a succinct assessment and plan. This matches a quick, focused re-evaluation to confirm progress and decide on the next steps without adding substantial data or risk.

If the re-exam were more complex—involving more symptoms, more data to review, or higher risk—the appropriate level would be higher, with more extensive history, exam, and a greater decision-making burden.