Proper documentation should include the reason for the visit, history, examination findings, medical decision-making, date of service, and the patient's relevant medical history. Accurate records are crucial for billing and clinical care.

CPT codes 99201-99205 represent a series of evaluation and management services for patient office visits. These codes cover a range of new or established patient encounters, each with varying levels of complexity. They are vital for documenting the medical evaluation and management of patients in an office or clinical setting, ensuring that healthcare professionals are appropriately compensated for their services and expertise.

These codes are used for the evaluation and management of patients during office visits, covering a range of clinical purposes, from routine check-ups to diagnosing and managing various medical conditions.