Chapter 19 Exam

An established patient presents to the office with a recurrence of bursitis in both shoulders. Examination is limited only to the shoulders in which range of motion is good and full, but he has tenderness in the subdeltoid bursa. Both shoulders were injected in the deltoid bursa with 120mg Depo-Medrol. What CPT® code(s) is/are reported for this visit?

20610-50

A 5 year-old is brought to the Emergency Department by ambulance, He had been found floating in a pool for an unknown amount of time. EMS started CPR which was continued by the ED provider along with endotracheal intubation and placement of a CVC. The ER provider spent 1 hour with the critically ill patient. The ED provider makes a notation the 1 hour does not include the time for the other separate billable services. What CPT® codes are reported?

92950, 99291-25, 36556, 31500

A 37 year-old female is seen in the clinic for follow-up of lower extremity swelling. HPI: Patient is here today for follow-up of bilateral lower extremity swelling. The swelling responded to hydrochlorothiazide. DATA REVIEW: I reviewed her lab and echocardiogram. The patient does have moderate pulmonary hypertension. Exam: Patient is in no acute distress. ASSESSMENT: 1. Bilateral lower extremity swelling. This has resolved with diuretics; it may be secondary to problem #2. 2. Pulmonary hypertension: Etiology is not clear at this time, will work up and possibly refer to a pulmonologist. PLAN: Will evaluate the pulmonary hypertension. Patient will be scheduled for a sleep study.

99212

An established patient presents to the clinic today for a follow-up of his pneumonia. He was hospitalized for 6 days on IV antibiotics. He was placed back on Singulair and has been doing well with his breathing since then. An expanded problem focused exam was performed. Records were obtained from the hospital and the provider reviewed the labs and X-rays. The patient was told to continue antibiotics for another two weeks to 20 days, and the prescription Keteck was replaced with Zithromax. Patient is to return to the clinic in two weeks for recheck of his breathing and follow up X-ray. What CPT® code is reported?

99213

Mr. Flintstone is seen by his oncologist just two days after undergoing extensive testing for a sudden onset of petechiae, night sweats, swollen glands and weakness. After a brief review of history, Dr. B. Marrow re-examines Mr. Flintstone. The exam is documented as expanded problem focused and the medical decision making of moderate complexity. The oncologist spends an additional 45 minutes discussing Mr. Flintstone's new diagnosis of Hodgkin's lymphoma, treatment options and prognosis. What is/are the appropriate procedure code(s) for this visit?

99213, 99354

An established 47 year-old patient presents to the provider's office after falling last night in her apartment when she slipped in water on the kitchen floor. She is complaining of low back pain and no tingling or numbness. Provider documents that she has full range motion of the spine, with discomfort. Her gait is within normal limits. Straight leg raising is negative. She requested no medication. It is recommended to use heat, such as a hot water bottle. Provider's Assessment: Lower Back Muscle Strain. What E/M and ICD-10-CM codes are reported for this service?

99213, S39.012A, W01.0XXA, Y92.030

A 28 year-old female patient is returning to her provider's office with complaints of RLQ pain and heartburn with a temperature of 100.2. The provider performs a detailed history, detailed exam and determines the patient has mild appendicitis. The provider prescribes antibiotics to treat the appendicitis in hopes of avoiding an appendectomy. What are the correct CPT® and ICD-10-CM codes for this encounter?

99214, K37, R12

The provider admitted an 18 month-old infant to the hospital from his office to rule out sepsis. The infant is crying inconsolably. He has a large amount of gas in his bowel, no hematochezia associated with it. A comprehensive history, comprehensive exam and moderate decision making is documented. If cultures are negative and the patient remains afebrile for 48 hours, the infant will be discharged home. What CPT® code is reported for this visit?

99222

Dr. Jones documents Mrs. Smith's condition has improved during his third visit to her hospital room. Upon entering the room, he finds her sitting up in bed, watching television and eating breakfast. Dr. Jones performs a problem focused exam and low medical decision making. What CPT® code is reported?

99231

The physician was called to the hospital floor for the medical management of a 56 year-old patient admitted one day ago with aspiration pneumonia and COPD. No chest pain at present, but still SOB and some swelling in his lower extremities. Patient was tachypneic yesterday; lungs reveal course crackles in both bases, right worse than left. The physician writes instructions to continue with intravenous antibiotic treatment and respiratory support with ventilator management. He reviewed chest X-ray and labs. Patient is improving and a pulmonary consultation has been requested. What CPT® code is reported?

99231

Dr. Jones documents Mrs. Smith's condition has improved during his third visit to her hospital room. Upon entering the room, he finds her sitting up in bed, watching television and eating breakfast. Dr. Jones performs a problem focused exam and a low medical decision making. What CPT® code should be reported?

99232

A 90 year-old female was admitted this morning from observation status for chest pain to r/o angina. A cardiologist performs a comprehensive history and comprehensive exam. Her chest pain has been relieved with the nitroglycerin drip given before admission and she would like to go home. Doctor has written prescriptions to add to her regimen. He had given her Isosorbide, and she is tolerating it well. He will go ahead and send her home. We will follow up with her in a week. Patient was admitted and discharged on the same date of service. What CPT® code is reported?

99235

A 32 year-old patient sees Dr. Smith for a consult at the request of his PCP, Dr. Long, for an ongoing problem with allergies. The patient has failed Claritin and Alavert and feels his symptoms continue to worsen. Dr. Smith performs an expanded problem focused history and exam and discusses options with the patient on allergy management. The MDM is straightforward. The patient agrees he would like to be tested to possibly gain better control of his allergies. Dr. Smith sends a report to Dr. Long thanking him for the referral and includes the date the patient is scheduled for allergy testing. Dr. Smith also includes his findings from the encounter. What E/M code is reported?

99242

Subjective: 6 year-old girl twisted her arm on the playground. She is seen in the ED complaining of pain in her wrist. Objective: Vital Signs: stable. Wrist: Significant tenderness laterally. X-ray is normal Assessment: Wrist sprain Plan: Over the counter Anaprox. Give twice daily with hot packs. Recheck if no improvement. What is the E/M code for this visit?

99281

Mr. Trumph loses his yacht in a poker game and experiences a sudden onset of chest pain which radiates down his left arm. The paramedics are called to the casino he owns in Atlantic City to stabilize him and transport him to the hospital. Dr. H. Art is in the ER to direct the activities of the paramedics. He spends 30 minutes in two-way communication directing the care of Mr. Trumph. When EMS reached the hospital Emergency Department, Mr. Trumph is in full arrest with torsades de pointes (ventricular tachycardia). Dr. H. Art spends another hour stabilizing the patient and performing CPR. Defibrillation is performed with 250 joules to a NSR. What are the appropriate procedure codes for this encounter?

99288, 99291, 92950

An infant is born six weeks premature in rural Arizona and the pediatrician in attendance intubates the child and administers surfactant in the ET tube while waiting in the ER for the air ambulance. During the 45-minute wait, he continues to bag the critically ill patient on 100 percent oxygen while monitoring VS, ECG, pulse oximetry and temperature. The infant is in a warming unit and an umbilical vein line was placed for fluids and in case of emergent need for medications. How is this coded?

99291-25, 31500, 36510, 94610

A patient is in the hospital after a wedge resection of the left lung due to cancer. He has not been able to keep the lung inflated without a ventilator. A 45-minute team conference between the general surgeon who performed the surgery, a pulmonologist, an oncologist and a neurologist is held to discuss the best treatment for the patient. The patient and/or patient's family is not present. What CPT® code is reported?

99367

After moving across country, Ms. Robbins took her 2 year-old daughter to a new pediatric clinic for an annual physical. The provider completed an age / gender appropriate history, exam, and provided anticipatory guidance. He ordered no additional tests or immunizations. What CPT® code is reported?

99382

A 10 year-old girl is scheduled for her yearly physical with her pediatrician. At the time of the visit, the patient complains of watery eyes, scratchy throat and stuffy nose for the past two days. The provider performs the physical. He also performs an expanded problem history and exam and treats the patient for a URI. What CPT® code(s) is/are reported for this visit?

99393, 99213-25

A 3 year-old critically ill child is admitted to the PICU from the ER with respiratory failure due to an exacerbation of asthma not manageable in the ER. The provider starts continuous bronchodilator therapy and pharmacologic support along with cardiovascular monitoring and possible mechanical ventilation support. The provider documents a comprehensive history and exam and orders are written after treatment is initiated. What is the CPT ® code for this encounter?

99475

A patient is seen by Dr. B who is covering on call services for Dr. A. The patient is an established patient with Dr. A. but she has not been seen by Dr. B. before. Which E/M subcategory is appropriate to report the services provided by Dr. B?

Established patient office visit

What ICD-10-CM code is reported for angina pectoris with a documented spasm?

I20.1

Which elements of HPI are met in this statement? Patient complains of headache and blurry vision for the past 3 days.

Location, quality and duration

If the pain is sharp, stabbing or dull, what is the component of the History of Present Illness (HPI)?

Quality

A patient is diagnosed as having both acute and chronic tonsillitis. How is this reported in ICD-10-CM?

The acute tonsillitis is reported first; the chronic tonsillitis is reported second.