Discussion: Unit 2 –  Review of Selected SOAP Note

Discussion: Unit 2 –  Review of Selected SOAP Note

New Patient Encounter


It is anticipated that the initial discussion post should be in the range of 250-300 words. Response posts to peers have no minimum word requirement but must demonstrate topic knowledge and scholarly engagement with peers. Substantive content is imperative for all posts. All discussion prompt elements for the topic must be addressed. Please proofread your response carefully for grammar and spelling. Do not upload any attachments unless specified in the instructions. All posts should be supported by a minimum of one scholarly resource, ideally within the last 5 years. Journals and websites must be cited appropriately. Citations and references must adhere to APA format.

Classroom Participation:

Students are expected to address the initial discussion question by Wednesday of each week. Participation in the discussion forum requires a minimum of three (3) substantive postings (this includes your initial post and posting to two peers) on three (3) different days. Substantive means that you add something new to the discussion supported with citation(s) and reference(s), you are not just agreeing. This is also a time to ask questions or offer information surrounding the topic addressed by your peers. Personal experience is appropriate for a substantive discussion, however, should be correlated to the literature.

All discussion boards will be evaluated utilizing rubric criteria inclusive of content, analysis, collaboration, writing, and APA. If you fail to post an initial discussion or initial discussion is late, you will not receive points for content and analysis, you may however post to your peers for partial credit following the guidelines above.


Review of Selected SOAP Note

The comprehensive SOAP note under review is that of a 75-year-old White male who lost the love of his life 19 years ago and is currently unsure of how much longer he can go on like this.  I would utilize 99203 as the CPT code.  The logic to guide this code is because a provider should use E/M CPT codes 99201-99205 or 99215 for any depression claim with ICD-9-CM diagnosis code. According to Shah & Lustig (2015), a primary care provider must be conversant with the new CPT codes that fall into five groups, namely initial evaluation codes and E/M codes for any patient encounter related to medical services. Others are psychotherapy, interactive code, and crisis services. Another reason why 99203 is most appropriate is that it is the CPT code for office or other outpatient visits for E/M of a new patient that demands medically appropriate history and examination with a low level of decision making (Carlo et al., 2020).

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Review of Selected SOAP Note
Review of Selected SOAP Note

There was the coordination of care services since the PCP referred the patient to counseling for depression, where I projected between 16 and 30 minutes would be consumed. Maurer et al. (2019) opine that the PHQ-2 adult screening instrument for depression is commonly utilized in primary care. The instrument’s use would also indicate the severity. As such, I avoided using psychiatric or psychotherapy CPT codes (90801- 90899) in this claim because they are not used in primary care settings. These codes are reserved for psychiatric or psychological practitioners only.


Carlo, A. D., Drake, L., Ratzliff, A. D., Chang, D., & Unützer, J. (2020). Sustaining the collaborative care model (CoCM): billing newly available CoCM CPT codes in an academic primary care systemPsychiatric Services71(9), 972-974.

Maurer, D. M., Raymond, T. J., & Davis, B. N. (2018). Depression: screening and diagnosis. American family physician98(8), 508-515.

Shah, V. N., & Lustig, S. L. (2015). The new, confusing CPT codes: tips for documenting and billing to get paid what you deserve.

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Cathy, CS