E/M for an Acute Problem

Question:

How do we code for a new patient seen in the office with RUQ upper quadrant discomfort with suspected cholecystitis and an order for ultrasound?

Answer:

A new patient with an acute problem (or “suspected” may be viewed as undiagnosed), with minimal data (order) and minimal/low risk for the ultrasound, would be 99203.

*This response is based on the best information available as of 4/24/25.