As this is a new patient who has never been established at this facility or has not been to this facility in the last 3 years (Penik, 2020), the new patient encounter I would use the 99204-code allowing for 45-59 minutes. I believe it would take this amount of time to meet and learn about a new patient, obtain the history of present illness, past medical history to include allergies medications, social history, family history, and health maintenance and promotion history. The review of systems covered 16 systems. For the number of diagnoses and management options, the patient has two diagnoses the first being Tinia Versicolor and the second being Alcohol abuse this would give the patient a 3 on the diagnosis/management option scale as this is a new problem and there is no work up planned. For the amount/complexity of data reviewed the patient would receive a two as we independently reviewed the specimen of the KOH test to determine it showed fungal spores. Lastly, for the risk of complications, morbidity, and mortality scale the patient would score a low risk level. According to the chart from the homework significant family history of cardiac disease, hypertension and stroke, his personal alcohol abuse, smoking, and risky lifestyle of being a truck driver who does not wear his seatbelt 50% of the time put him at risk for serious complications but the chart does not appear to take that into account until after something happens. This is a patient who is letting a skin rash progress for 2 months before seeking medical care which I feel puts him in a high-risk category. That being said the risk of significant complication, morbidity, or mortality score would be a minimal risk.
Chart provided from the reading is depicted below (Penik, 2020).
Diagnoses/management options score- 3
Amount/Complexity of Data Reviewed Score- 2
Risk of Significant Complications, Morbidity, or Mortality- minimal risk