Coding: Evaluation & Management Ch. 19

What modifier is used to report an evaluation and management service mandated by a court order?

32 Rationale: Modifier 32 is used for services related to mandated consultation and/or related services by a third party payer, governmental, legislative or regulatory requirements.

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 Rationale: ED provider documents an amount of time spent with this critical patient. According to CPT® guidelines: "The critical care codes 99291 and 99292 are used to report the total duration of time spent by a provider providing critical care services to a critically ill or critically injured patient. Time spent with individual patient is recorded in the patient's record." According to CPT® guidelines: "Services such as endotracheal intubation (31500) and cardiopulmonary resuscitation (92950) are not included in the critical care codes. Therefore, they can be coded separately in addition to critical care services if the critical care is a significant, separately identifiable service, and is reported with modifier -25. The time spent performing these other services, for example endotracheal intubation, is excluded from the determination of the time spent providing critical care." In the CPT® Index look for Cardiopulmonary Resuscitation (CPR), you are referred to code 92950. Review code to verify accuracy. In the CPT® Index look for Catheterization/Central, you are referred to codes 36555-36566. 36556 is the correct code because the patient is 5 years of age and there is no indication the CVC was tunneled. In the CPT® Index look for Intubation/Endotracheal Tube, you are referred to code 31500. Review code to verify accuracy.

A new patient is seen in the pediatric office for ear pain. The patient has had pain for four days and it keeps her awake at night. She has had a slight fever (100.7°F). She has not been swimming or actively in water for the past couple of months. She denies any cough, nasal congestion, or stuffiness, or loss of weight. The provider does a limited exam on the ears, nose, throat, and neck. The patient is determined to have otitis media. Amoxicillin is prescribed.What is the correct E/M code reported for this visit?

99202 Rationale: For a new patient visit, all three key components must be met:History - HPI (Extended), ROS (Extended), PFSH (none) = EPFExam - Expanded problem focused (limited exam of ears, nose, throat, and neck)MDM - Moderate for the prescription drug management.The documentation supports 99202.

A new patient visits the internal medicine clinic today for diabetes, chronic constipation, arthritis and a history of cardiac disease. The provider performs a detailed history, comprehensive exam and a medical decision making of moderate complexity. What CPT® code is reported?

99203 Rationale: In the CPT® Index look for Office and/or Other Outpatient Services/Office Visit/New Patient and you are directed to codes 99201-99205. For New Patient visits, all three key components must be met. This service supports a level 3 new patient visit, 99203.

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 Rationale: This is a follow-up visit indicating an established patient seen in the clinic. In the CPT® Index look for Established Patient/Office Visit. The code range to select from is 99211-99215. For this code range, two of three key components must be met. History Problem Focused (HPI Brief, ROS None, PFSH Pert), Exam Problem Focused, MDM Moderate (Management options: 1 stable problem, one new problem with workup; Data reviewed: lab and EKG; Level of Risk Moderate with unknown cause of pulmonary HTN). 99212 is the level of visit supported.

An established patient is seen in clinic for allergic rhinitis. A problem focused history, an expanded problem focused exam, and a low level of medical decision making are performed. What E/M code is reported for this visit?

99213 Rationale: Established patient codes require two of three key components be met to determine a level of visit. In this case, the expanded problem focused exam and low level of medical decision making support a level 3 established patient office visit 99213.

An established 47 year-old patient presents to the provider's office after falling last night in her apartment when she slipped on 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 Rationale: The patient is an established patient. In the CPT® Index look for Established Patient/Office and/or Other Outpatient/Office Visit. You are referred to 99211-99215. An established patient visit requires 2 of 3 key components. The provider documents an Expanded Problem Focused History (brief HPI, pertinent ROS, and no PFSH), a Problem Focused Exam (1 affected organ system, musculoskeletal) and Low MDM (New Problem to examiner, no additional work-up, 0 data points, and acute complicated injury, e.g., simple sprain). Review codes to choose the appropriate level of service. Code 99213 is the correct code. Lower Back Muscle Strain was the provider's diagnosis. In the ICD-10-CM Alphabetic Index look for Strain/low back. You are referred to S39.012-. Tabular List shows that a 7 th character is reported. A is reported for the initial encounter. Next go to the External Cause of Injuries Index. Look for Slipping (accidental) (on same level) (with fall)/on/surface (slippery) (wet) NEC. You are referred to W01.0-. In the Tabular List placeholders of X are needed for the 5th and 6th characters. The 7th character is reported with A to indicate initial encounter. Next look for Place of occurrence/residence/apartment/kitchen. You are referred to Y92.030. Review the code in Tabular List to verify accuracy.

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 Rationale: This is an established patient E/M level of service due to the indication she returning to her provider for the visit. Code 99214 is appropriate when two of the three key components are met for an established patient. According to the ICD-10-CM guidelines I.B.4 or I.B.18, a definitive diagnosis is reported when it has been established. Look in the ICD-10-CM Alphabetic Index for Appendicitis which directs you to K37. Guideline I.B.5 indicates any signs or symptoms that would be an integral part of that definitive diagnosis/disease process would not be separately reported. Heartburn is not a symptom commonly seen with appendicitis so we can report this as an additional code, refer to guideline I.B.6. Look in the Alphabetic Index for Heartburn which directs you to R12. Verification in the Tabular List confirms code selections.

Dr. Howitzer sees Mrs. Jones in Clinic Eight for sudden loss of consciousness while watching the Olympic Torch go by. He is a new provider to the neurology department. Dr. Drake Rinaldi, a prominent member of the neurology faculty at the university saw Mrs. Jones last month. Dr. Howitzer performs a history including 3 HPI elements and 2 ROS, a detailed exam and has medical decision making of high complexity. The final diagnosis given is transient loss of consciousness. The patient makes a follow-up appointment to see Dr. Rinaldi in one week. What is the appropriate diagnosis and E/M code for this visit?

99214, R55 Rationale: E/M Guidelines define an established patient as one who has received professional services from the provider or another provider of the same specialty who belongs to the same group practice within the past three years. The patient was seen the previous month by another member in the same group practice of the neurology department making this an established patient. The level of history is expanded problem focused defined by a brief HPI and an extended ROS. The exam is described as detailed and the MDM is of high complexity. For an established patient, you must meet or exceed two of the three key elements, making this a detailed visit. Two of the three key elements in this visit meet the requirements for 99214. Look in the ICD-10-CM Alphabetic Index for Loss (of)/consciousness, transient directing you to code R55. Verify code selection in the Tabular List.

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 Rationale: According to CPT® guidelines: "When the patient is admitted to the hospital in the course of an encounter in another site of service (for example hospital emergency, department, provider's office, nursing facility) all evaluation and management services provided by that provider in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission." The provider admitted the infant to the hospital from his office and continued the care on the same date of service. The provider documented a comprehensive history, comprehensive exam and moderate MDM. The appropriate code is 99222.

The physician was called to the hospital floor for the medical management of a 56 year-old patient who he admitted one day ago with chest pain due to aspiration pneumonia and COPD. Patient indicates no chest pain at present, but still SOB and some swelling in his lower extremities. Patient was tachypneic yesterday; examination of the lungs reveals course crackles in both bases, right still 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 Rationale: Physician is providing subsequent hospital care to an inpatient. The physician performed an expanded problem focused interval history (brief HPI, extended ROS since last assessment), problem focused exam (1 system), and low MDM (prescription drug management, two data points [reviewing X-ray and labs], and established diagnosis is improving. Subsequent hospital codes require two out of three key components. The code documented is 99231.

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 Rationale: This patient was admitted and discharged on the same date of service from observation status. According to CPT® guidelines for Observation or Inpatient Care Services (Including Admission and Discharge Services), services for a patient admitted and discharged on the same date of service is reported by one code. For a patient admitted and discharged from observation or inpatient status on the same date, codes 99234-99236 is reported as appropriate." The provider performed a comprehensive history, comprehensive exam, and moderate MDM (New problem to the examiner, 0 data points and moderate risk). The correct code is 99235.

Dr. Inez discharges Mr. Blancos from the pulmonary service after a bout of pneumococcal pneumonia. She spends 45 minutes at the bedside explaining to Mr. Blancos and his wife the medications and IPPB therapy she ordered. Mr. Blancos is a resident of the Shady Valley Nursing Home due to his advanced Alzheimer's disease and will return to the nursing home after discharge. On the same day Dr. Inez re-admits Mr. Blancos to the nursing facility. She obtains a detailed interval history, does comprehensive examination and the medical decision making is moderate complexity. What is/are the appropriate evaluation and management code(s) for this visit?

99239, 99304 Rationale: Hospital discharge is a time-based code. The documentation states that the provider spent 45 minutes discharging the patient. In the CPT® Index look for Hospital Services/Discharge Services. Code 99239 is for 30 minutes or more. Upon discharge the patient was readmitted to a skilled nursing facility (SNF) where he is a resident. CPT® guidelines preceding the Initial Nursing Facility Care codes state when a patient is discharged from the hospital on the same day and readmitted to a nursing facility both the discharge and readmission is reported. Initial nursing facility care codes require the three key components to meet or exceed the requirements. Documentation tells us the physician provided a detailed history, comprehensive exam, and medical decision making was of moderate complexity. Code 99304 states the history and exam can be detailed or comprehensive. Our documentation shows it to be of moderate complexity, which meets the requirements. Because our history is only detailed, the requirements are not met for 99305.

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 Rationale: The three Rs of consultation are documented (request, render, reply). The consultation code range is 99241-99245 and applies to new or established patients. Consultations require three key components. The documentation states the history and exam were expanded problem focused and the MDM is straightforward. These three key elements meet the requirement for 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 normalAssessment: Wrist sprainPlan: Over the counter Anaprox. Give twice daily with hot packs. Recheck if no improvement.What is the E/M code for this visit?

99281 Rationale: Emergency Department services must meet or exceed three of the three key components. The provider performed a problem focused history (brief HPI, no ROS, no PFSH), a problem focused exam (one body area is examined) and low MDM (for one new problem to the examiner, one data point for the X-ray, and low level of risk). The problem focused history and exam lead us to select 99281 as the appropriate code.

A 25 year-old male is brought by EMS to the Emergency Department for nausea and vomiting. Patient has elevated blood sugars and the ED provider is unable to get a history due to patient's altered mental status. An eight organ system exam is performed and the MDM is high. The patient was stabilized and transferred to ICU. The ED provider documents total critical care time 25 minutes. What CPT® code is reported? s clinical condition and/or mental status.

99285 Rationale: According to CPT® Critical Care Services guidelines: "99291 is used to report the first 30-74 minutes of critical care on a given date. Critical care of less than 30 minutes of total duration on a given date is reported with the appropriate E/M code." For this encounter the provider is short 5 minutes of 30 minutes needed to bill the critical care code. The encounter takes place in the emergency department. In the CPT® Index look for Evaluation and Management/Emergency Department. You are referred to 99281-99285. For emergency room services, three out of three key components are required. In this case, the provider is unable to obtain a history due to the patient's condition. According to the CMS Documentation Guidelines, the provider must indicate the reason they could not obtain a history. The level is determined by the exam and MDM. The exam is comprehensive (eight organ systems) and MDM is high. The proper code is 99285. There is also a statement in the description of 99285 that states, "within the constraints imposed by the urgency of the patient's clinical condition and/or mental status.

ICU - CC: Multi-system organ failure INTERVAL HISTORY: Patient remains intubated and sedated. Overnight events reviewed. Tolerating tube feeds. Systolic pressures have been running in the low 90s on LEVOPHED. Cultures remain negative. Kidney function has worsened, but patient remains non-oliguric.PHYSICAL EXAM: BP 96/60, Pulse 112, Temp 100.8. Lungs have anterior rhonchi. Heart RRR with no MRGs. Abdomen is soft with positive bowel sounds. Extremities show moderate edema.LABS: BUN 89, creatinine 2.6, HGB 10.2, WBC 22,000. ABG: 7.34/100/42 on 50% FiO2. CXR shows RLL infiltrate.IMPRESSION Hypoxic respiratory failureCommunity acquired pneumoniaSeptic shockNon-oliguric acute renal failurePLAN: Continue NS at 75 cc/hr. Decrease ZOSYN to 2.25 grams IV Q 6HFollow cultures. Continue tube feeds. Titrate LEVOPHED to maintain SBP > 90Usual labs ordered for tomorrow.Critical care time: 35 minutesWhat CPT® code(s) is/are reported?

99291 Rationale: This patient meets the definition of a critically ill patient as defined by the E/M Guidelines for Critical Care services. A critical illness is one acutely impairing one or more vital organ system with a high probability of imminent or life threatening deterioration in the patient's condition. The physician documents 35 minutes of critical care time. Critical care for 35 minutes is reported with 99291.

A pediatrician is asked to be in the room during the delivery of a baby at risk for complications. The pediatrician is in the room for 45 minutes. The baby is born and is completely healthy, not requiring the services of the pediatrician. What CPT® code(s) is/are reported by the pediatrician?

99360 Rationale: The physician provider standby services. In the CPT® Index look for Standby Services and you are directed to 99360. 99360 is reported based on time. Each 30 minutes is reported if only the entire 30 minutes is met. 99360 with 1 unit is the correct code choice.

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 Rationale: This is a new patient to the pediatric clinic. Look in the CPT® Index for Preventive Medicine/New Patient and you are directed to code range 99381-99387. The code selection is based on age. Code 99382 is for ages 1-4 making it the correct code choice.

Patient comes in today at 4 months of age for a checkup. She is growing and developing well. Her mother is concerned because she seems to cry a lot when lying down but when she is picked up she is fine. She is on breast milk, but her mother has returned to work and is using a breast pump but has not seemed to produce enough milk.PHYSICAL EXAM: Weight 12 lbs. 11 oz., Height 25in., OFC 41.5 cm. HEENT: Eye: Red reflex normal. Right eardrum is minimally pink, left eardrum is normal. Nose: slight mucous Throat with slight thrush on the inside of the cheeks and on the tongue. LUNGS: clear. HEART: w/o murmur. ABDOMEN: soft. Hip exam normal. GENITALIA normal although her mother says there was a diaper rash earlier in the week.ASSESSMENTFour month-old well checkColdMild thrushDiaper rashPLAN:Okay to advance to baby foodsOkay to supplement with SimilacNystatin suspension for the thrush and creams for the diaper rash if it recursMother will bring child back after the cold symptoms resolve for her DPT, HIB and polioWhat E/M code(s) is/are reported?

99391 Rationale: Documentation states the encounter is for a checkup, which is a Preventive Medicine Service. In the CPT® Index look for Preventive Medicine/Established Patient. Preventive Medicine Service codes are age specific. Although the child has a cold and thrush, additional history and exam elements beyond what is performed in the preventative exam are not documented. It would be inappropriate to bill for an additional E/M service with the modifier 25. See Appendix A for a description of modifier 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 Rationale: This visit meets the criteria for Inpatient Neonatal and Pediatric Critical Care. Codes 99471-99476 are used to report the direction of the inpatient care of a critically ill infant or young child from 29 days through less than 6 years. Codes are further divided by initial and subsequent care. This is the initial care of a critically ill 3 year-old. Services provided in the ER by the admitting provider may not be coded. When a neonate, infant or child requires initial critical care services on the same day the patient has already received hospital care or intensive care services by the same provider, only the initial critical care service code (99468, 99471, 99475) is reported. Code 99475 is the correct code for this service.

Where are clinical examples for evaluation and management codes found in the CPT® code book?

Appendix C Rationale: Appendix C of the CPT® code book contains clinical examples of evaluation and management codes. The appendix may be used in addition to the E/M code descriptors.

Established patientCHIEF COMPLAINT: Fever.PRESENT ILLNESS: The patient is a 2-year, 3-month-old female with less than 1 day of a high fever with decreased appetite. There has been no vomiting or diarrhea. Parents are unaware of any cough. Tylenol has been given which reduced the fever.PAST MEDICAL HISTORY: Otherwise negative.CURRENT MEDICATIONS; Tylenol® 160 mg q.4 h. per infant Tylenol® drops.ALLERGIES; NONE.IMMUNIZATIONS: Up to date.REVIEW OF SYSTEMS: As per HPI. Rest of review of systems reviewed and negative.PERSONAL, FAMILY, SOCIAL HISTORY: The patient is not exposed to secondhand cigarette smoke.What is the level of history?

Comprehensive CC: FeverHPI: Duration - Less than one day Severity - High fever Associated signs and symptoms - Decreased appetite Modifying factor - Tylenol® has been given which reduced the fever.ROS: GI - No vomiting or diarrhea Resp - Parents unaware of any cough Rest of review of systems reviewed and negative: Complete ROSPFSH: Personal history - Current meds Social history - Not exposed to second hand smoke

Physical Exam:General/Constitutional: No apparent distress. Well nourished and well developed.Ears: TM's gray. Landmarks normal. Positive light reflex.Nose/Throat: Nose and throat clear; palate intact; no lesions.Lymphatic: No palpable cervical, supraclavicular, or axillary adenopathy.Respiratory: Normal to inspection. Lungs clear to auscultation.Cardiovascular: RRR without murmurs.Abdomen: Non-distended, non-tender. Soft, no organomegaly, no masses.Integumentary: No unusual rashes or lesions.Musculoskeletal: Good strength; no deformities. Full ROM all extremities.Extremities: Extremities appear normal.What is the level of exam?

Comprehensive Rationale: Organ Systems: Constitutional, ENMT, Lymphatic, Respiratory, Cardiovascular, Gastrointestinal, Skin, Musculoskeletal. There are 8 organ systems examined. The level of exam is Comprehensive.

Physical Exam:CONSTITUTIONAL: Vital Signs: Pulse: 161. Resp: 30. Temp: 102.4. Oxygen saturation 90% GENERAL APPEARANCE: The patient reveals profound mental retardation. Tracheostomy is in place. EYES: Conjunctivae are slightly anemic. ENT: Oral mucosa is dry. NECK: The neck is supple and the trachea is midline. Range of motion is normal. There are no masses, crepitus or tenderness of the neck. The thyroid gland has no appreciable goiter. RESPIRATORY: The lungs reveal transmitted upper airway signs and bilateral rales, wheezes and rhonchi. CARDIOVASCULAR: The chest wall is normal in appearance. Regular rate and rhythm. No murmurs, rubs or gallops are noted. There is no significant edema to the lower extremities. GASTROINTESTINAL: The abdomen is soft and nondistended. There is no tenderness, rebound or guarding noted. There are no masses. No organomegaly is appreciated. SKIN: The skin is pale and slightly diaphoretic. NEUROLOGIC: Cranial nerves appear intact. The patient moves all 4 extremities symmetrically. No lateralizing signs are noted. Gross sensation is intact to all extremities. LYMPHATIC: There are no palpable pathologic lymph nodes in the neck or axilla. MUSCULOSKELETAL: Gait and station are normal. Strength and tone to the upper and lower extremities are normal for age with no evidence of atrophy. There is no cyanosis, clubbing or edema to the digits.What is the level of exam?

Comprehensive Rationale: Organ Systems: Constitutional, Eyes, ENMT, Respiratory, Cardiovascular, Gastrointestinal, Integumentary, Neurologic, Lymphatic, Musculoskeletal. Ten organ systems were examined. The level of exam is Comprehensive.

Fred is fishing at the local area lake while on vacation. He gets lightheaded and dizzy and goes to the local hospital Emergency Department. He is evaluated by the ED provider. This is the first time he has been to this hospital. What subsection is used to report the ED visit?

Emergency Department Services Rationale: No distinction is made between new and established patients in the emergency department. Evaluation and Management services provided in an Emergency Department are reported with codes from the Emergency Department Services Subsection 99281-99285.

HISTORY OF PRESENT ILLNESSA 73-year-old man who is a veterinarian is seen here for the first time today. He has a history of squamous cell carcinoma on the left arm and a basal cell carcinoma on the right forehead near the temple, both in January 20XX. He says he has had a lesion on his forehead for approximately one year. He is concerned about what it is and thinks it may be another skin cancer. He is also concerned about another lesion that has been present for a while, just lateral to his right eye. He would also like a full skin check today. He uses a hat for sun protection. He has lived in California and has had significant sun exposure in the past.REVIEW OF SYSTEMS: Otherwise well, no other skin complaints.PAST MEDICAL HISTORYCoronary artery disease status post bypass surgery, history of squamous andbasal cell carcinomas as noted above, hay fever, and hyperlipidemia. Hehas had lipomas removed.MEDICATIONS: Tylenol, tramadol, thyroxin, fish oil, flax seed oil, simvastatin, Zyrtec®, 5% saline in eyes.ALLERGIES: No known drug allergies.FAMILY HISTORY: No family history of skin cancer or other skin problems.SOCIAL HISTORY: Patient is a veterinarian. He recently moved to the Rochester area from Pennsylvania. He is married.What is the level of history?

Expanded problem focused CC: Skin lesionsHPI: Location - Forehead and lateral to right eye Duration - About a yearROS: Integumentary - No other skin complaints Stated, "Otherwise well", this is not an indication that all other systems were reviewed.PFSH: Past, Family, and Social all reviewed as it relates to skin.

Subsequent Hospital VisitLABS: BUN 56, creatinine 2.1, K 5.2, HGB 12.IMPRESSION:1. Severe exacerbation of CHF2. Poorly controlled HTN3. Worsening ARF due to cardio-renal syndromePLAN:1. Increase BUMEX to 2 mg IV Q6.2. Give 500 mg IV DIURIL times one.3. Re-check usual labs in a.m.Total time: 20minutes.What is the level of medical decision making?

High Rationale: Three problems worsening (six points); labs reviewed (one point); chronic illnesses posing a threat to life (exacerbation of congestive heart failure, poorly controlled hypertension, worsening acute renal failure due to cardio-renal syndrome). The medical decision making is High.

John, a 16-year-old male, is admitted by the emergency department physician for observation after an ATV accident. The patient is discharge from observation by another provider the next day. What category or subcategory of evaluation and management codes would be selected for the emergency department physician?

Initial observation care Rationale: The patient presented to the Emergency Department and was admitted to observation by the ED physician. The guidelines for Initial Observation Care state that all services provided by the admitting physician for the same date of service are included in the initial hospital care, and in this instance the emergency department services would not be coded. If the patient was discharged on the same date of service, a code from Observation or Inpatient Care Services (Including Admission and Discharge Services) would be selected.

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 Rationale: Location (headache), quality (blurry), duration (past three days).

Office Visit:Here for six month check upHPI: Follow up evaluation of DM and hypertension... She is under a lot of stress. No other new problems or complaints.A/P: DM, essential hypertensionPlan is to continue the same. Return to office in 6 months for follow up.What is the level of medical decision making?

Low Rationale: The patient is in for follow up of chronic conditions. The conditions are both established and stable (two points). There is no data reviews and moderate risk (two stable chronic conditions). Medical decision making is Low.

A PCP transfers a patient to a cardiologist for management of the patient's congestive heart failure. The cardiologist examines the patient, discusses treatment options and schedules a stress test for this new patient. A report is sent to the PCP detailing the findings of the office visit, results of the stress test and intent to manage and treat the congestive heart failure. An E/M code would be selected from what subcategory for the cardiologist?

New patient office visit Rationale: The PCP transferred the patient to the cardiologist to manage/treat the congestive heart failure. The cardiologist accepted the transfer of care of the patient and sent a letter to the PCP with findings of the first visit and stress test. This would be coded as a new patient since the cardiologist accepted the patient and is taking over the care of a specific problem.

A mother takes her 2-year-old back to Dr. Denton for an annual well child exam. The patient has a comprehensive check-up and vaccinations are brought up to date. Which category or subcategory of evaluation and management codes would be selected for the well child exam?

Preventive medicine, established patient Rationale: The mother "takes her 2-year-old back to Dr. Denton" indicates this is an established patient. This is a well child exam with no complaints and a code from preventive medicine, established patient, would be selected. The preventive medicine, individual counseling codes are used for risk reduction such as diet and exercise, substance abuse, family problems, etc.

CASE 3 Susan is a 67 years-old female and she is referred by Dr. R with a suspicious neoplasm of her left arm.(Chief Complaint) She has had it for about a year, but it has grown a lot this last few months. (Related to surgery.) I had the privilege of taking a skin cancer off her forearm in the past. (Established patient.) PAST MEDICAL HISTORY: Hypertension, arthritis. ALLERGIES: None. MEDICATIONS: Benicar and Vytorin. SOCIAL HISTORY: Cigarettes: None. PHYSICAL EXAMINATION: On examination, she has a raised lesion. It is a little bit reddish and is on her left proximal arm. It has a little bumpiness on its surface. (Related to surgery.) MEDICAL DECISION MAKING: Suspicious neoplasm, left arm. My guess is this is a wart, but it may be a keratoacanthoma (Possible diagnoses are not coded.) as Dr. R thinks it is. After obtaining consent, we infiltrated the area with 1cc of 1% lidocaine with epinephrine, performed a 3-mm punch biopsy of the lesion, and then I shaved the rest of the lesion off and closed the wound with 3-0 Prolene.(Punch biopsy and shaving of the lesion are performed.) We will see her back next week to go over the results. What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM codes: [b], [c]

Specified Answer for: a 11300 Specified Answer for: b D49.2 Specified Answer for: c Z85.828

CASE 5 Mark is a 45-years-old male and is here as a new patient (New patient) to have several lipomas removed.(Chief complaint) He has had these for many years.(HPI: Duration) He has had about 12 removed.(ROS: Integumentary) They get bigger slowly over time. (HPI: Severity) Some of them are tender to touch. (HPI: Quality) They get irritated when he is handling people as a firefighter. (HPI: Modifying factors) PAST MEDICAL HISTORY: None. ALLERGIES: None. MEDICATIONS: None. PAST SURGICAL HISTORY: Nasal surgery, knee surgery. (Past medical history) SOCIAL HISTORY: Cigarettes: None. (Social history) FAMILY HISTORY: He does have a family history of melanoma in his paternal grandfather who died from it. (Family history) PHYSICAL EXAMINATION: On examination, he has subcutaneous masses of his left forearm and two spots of his left posterior arm. That is the biggest of those three. It is about 1.3 cm. He has four on his right upper extremity, two on his lower forearm and two on his posterior arm. He has some of his belly. (Organ: Skin) MEDICAL DECISION MAKING: The patient has multiple lipomas (Diagnosis) which are tender. He would like them removed. With his permission, I have drawn how we would incise the skin over these and about how long the scar would be. There is really no alternative to treatment other than surgery. Some plastic surgeons will do this with liposuction, but I have found that personally the recurrence rate is quite high when I have tried to do it with liposuction, so I generally just excise them. Risks would include infection and bleeding. (Elective major surgery (removal of subcutaneous lipoma has a 90-day global); although provider documents risk of infection and bleeding, this is not above the normal risk associated with a surgery.) We do not know why people get these, so this is something that Mark will have to deal with forever. We will do that here in the office. We will do about three at a time. We are going to start with his left upper extremity. It will be a privilege to take care of Mark. What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM codes: [b], [c], [d]

Specified Answer for: a 99201 Specified Answer for: b D17.21 Specified Answer for: c D17.22 Specified Answer for: d D17.1

CASE 2 The patient is a 32-year-old male here for the first time. (New patient.) Chief Complaint: Left knee area is bothersome,(Chief complaint.) painful moderate severity.(HPI: Severity) The patient also notes swelling (HPI: Associated Signs & Symptoms) in the knee area,(HPI: Location) limited ambulation,(HPI: Severity again (not counted twice)) and inability to perform physical activities such as sports or exercises. The patient first noticed symptoms approximately 4 months ago. (HPI: Duration) Problem occurred spontaneously. Problem is sporadic.(HPI: Timing) Patient has been prescribed hydrocodone and meloxicam. Patient has had temporary pain relief with the medications. The meloxicam has caused digestion problems, so patient has avoided using it. (HPI: Modifying factors and their affects.) Past Medical History: Patient denies any past medical problems. Surgeries: Patient has undergone surgery on the appendix. Hospitalizations: Patient denies any past hospitalizations that are noteworthy. Medications: Hydrocodone Allergies: Patient denies having allergies. (PFSH: Past Medical History) Family History: Mother: No serious medical problems; Father: No serious medical problems.(PFSH: Family History) Social History: Patient is married. Occupation: Patient is a chef. (PFSH: Social History) Review of Systems: Constitutional: Denies fevers. Denies chills. Denies rapid weight loss. Eyes: Denies vision problems. Ears, Nose, Throat: Denies any infection. Denies loss of hearing. Denies ringing in the ears. Denies dizziness. Denies a sore throat. Denies sinus problems. Cardiovascular: Denies chest pains. Denies an irregular heartbeat. Respiratory: Denies wheezing. Denies coughing. Denies shortness of breath. Gastrointestinal: Denies diarrhea. Denies constipation. Denies indigestion. Denies any blood in stool. Genitourinary: Denies any urine retention problems. Denies frequent urination. Denies blood in the urine. Denies painful urination. Integumentary: Denies any rashes. Denies having any insect bites. Neurological: Denies numbness. Denies tremors. Denies loss of consciousness. Hematologic/Lymphatic: Denies easy bruising. Denies blood clots. Psychiatric: Denies depression. Denies sleep disorders. Denies loss of appetite. (ROS: Complete) Review of Previous Studies: Patient brings an MRI which is reviewed. Large knee effusion. No lateral meniscal tear. No ACL/PCL tear. No collateral fracture. Medial meniscus tear with grade I signal. (Previous studies reviewed used in MDM.) Vitals: Height: 6'0", Weight: 160 Physical Examination: Patient is alert, appropriate, and comfortable. Patient holds a normal gaze. Pupils are round and reactive. (Exam: Eyes) Gait is normal. (Exam: Musculoskeletal) Skin is intact. No rashes, abrasions, contusions, or lacerations. (Exam: Skin)No venous stasis. No varicosities. (Exam: Cardiovascular) Reflexes are normal patellar. No clonus.(Exam: Neuro) Knee: Range of motion is approximately from 5 to 100 degrees. Pain with motion. No localized pain. Negative mechanical findings. There is an effusion. Patella is tracking well. No tenderness. Patient feels pain especially when taking stairs or squatting. Hip: Exam is unremarkable. Normal range of motion, flexion approximately 105 degrees, extension approximately 10 degrees, abduction approximately 25 degrees, adduction approximately 30 degrees, internal rotation approximately 30 degrees, external rotation approximately 30 degrees. (Exam: Musculoskeletal) Neck: Neck is supple. No JVD. (Exam: Neck) Impression: 1. Infective synovitis of the left knee 2. Contracture of the left knee 3. Possible medial meniscal tear of right knee (Uncertain diagnosis) Assessment and Plan: A discussion is held with the patient regarding his condition and possible treatment options. Patient has GI upset. Patient is recommended to take Motrin 400 two to three times a day (Over the counter medication), discussion is held regarding proper use and precautions. Patient is given a prescription for physical therapy.(Physical therapy prescribed) We will obtain an MRI (Additional test ordered) to rule out potential medial meniscus tear. Patient is instructed to follow up with PMD with labs. Patient is referred to Dr. XYZ. Patient may need arthroscopy if patient does have medial meniscus tear and repeat effusion. (Uncertain prognosis on the tear. The patient is sent for additional work-up to determine if there is a tear present.) What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM codes: [b], [c]

Specified Answer for: a 99203 Specified Answer for: b M65.162 Specified Answer for: c M24.562

CASE 1 IDENTIFICATION: The patient is a 37-year-old Caucasian lady. CHIEF COMPLAINT: The patient is here today for follow-up (Established patient & established problem.) of lower extremity swelling. (Chief complaint) HISTORY OF PRESENT ILLNESS: A 37-year-old with a history of dyslipidemia and chronic pain. (Past medical history) The patient is here for follow-up of bilateral lower extremity (HPI: Location) swelling. The patient tells me that the swelling responded to hydrochlorothiazide. (HPI: Modifying factor) EXAM: Very pleasant, no acute distress (NAD). VITALS: P: 67, R: 18, Temp 98.6, BP: 130/85. DATA REVIEW: I did review her labs, (Lab reviewed) and echocardiogram. (Echocardiogram review) The patient does have moderate pulmonary hypertension. ASSESSMENT: 1. Bilateral lower extremity swelling: This has resolved with diuretics; this may be secondary to problem #2.(Possibly due to pulmonary hypertension, but not certain, so code separately.) 2. Pulmonary hypertension: Etiology is not clear at this time, will do a work up and possible referral to a pulmonologist. PLAN: I think we will need to evaluate the etiology of the pulmonary hypertension. The patient will be scheduled for a sleep study. What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM codes: [b], [c]

Specified Answer for: a 99212 Specified Answer for: b M79.89 Specified Answer for: c I27.20

CASE 10 Established patient Chief complaint: thoracic spine pain PROBLEM LIST: 1. Rheumatoid arthritis, right and left hands. 2. Compression fracture of the thoracic spine T11. 3. Alcoholism. 4. Depression/anxiety. REVIEW OF SYSTEMS: His pain is significantly improved in his thoracic spine. He does have low back pain. He has a history of chronic low back pain. He is still wearing a thoracic support brace. He is going to follow up with Dr. X's office in about six weeks or so. Since I have seen him last he had a small flare of arthritis after his Humira injection. This resolved after 2-3 days. He had pain and stiffness in his hands. Currently he denies any pain and stiffness in his hands. He has one cystic mass on his left hand, second distal pad that is bothersome. CURRENT MEDICATIONS: Vasotec 20mg a day, Folic Acid 1mg a day, Norvasc 5mg a day, Pravachol 40mg a day, Plaquenil 400mg a day, Humira 40mg every other week, Celexa 20mg a day, Klonopin .5mg as needed, aspirin 81mg a day, Ambien 10mg as needed, Hydrocodone as needed. PHYSICAL EXAM: He is alert and oriented in no distress. Gait is unimpaired. He is wearing the thoracic brace. Spine ROM is not assessed. Lungs: Clear. Heart: Rate and rhythm are regular. MUSCULOSKELETAL EXAM: There is generalized swelling of the finger joints without any significant synovitis or tenderness. There is a cystic mass on the pad of his second left finger, which is tender. Remaining joints are without tenderness or synovitis. REVIEW OF DEXA(Dual Energy X-ray Absorptiometry) SCAN: (Performed in office today) There is low bone density with a total T-score of -1.1 of the lumbar spine. Compared to previous it was -0.8. There has been a reduction by 3.6%. T-score of the left femoral neck -1.1, Ward's triangle -2.4, and total T-score is -0.8 compared to previous there has been a 7% reduction from 2005. ASSESSMENT: 1. Seronegative rheumatoid arthritis in both hands. He is doing fairly well. He does have a cystic mass, which seems to be a synovial cyst of the left second digit. He was wondering if he could have this aspirated. 2. Senile osteoporosis and continued care for compression pathologic fracture. He is being treated for osteoporosis because of this. He is tolerating Fosamax well. He is also using Miacalcin nasal spray temporarily to help and it has been effective. PLAN: 1. Continue current therapy. 2. Aspirate the synovial cyst in the left second finger. 3. Follow up in about 6-8 weeks. 4. Repeat labs prior to visit. PROCEDURE NOTE: With sterile technique and Betadine prep, the radial side of the second finger is anesthetized with 1cc 1% Lidocaine for a distal finger block. Then the synovial cyst is punctured and material was expressed under the skin. I injected it with 20mg of Depo-Medrol. He will keep it clean and dry. If it has any signs or symptoms of infection, he will let me know. What are the CPT® and ICD-10-CM codes reported? CPT® codes: [a], [b], [c], [d] ICD-10-CM codes: [e], [f], [g], [h]

Specified Answer for: a 99213-25 Specified Answer for: b 20612-F1 Specified Answer for: c 77080 Specified Answer for: d J1020 Specified Answer for: e M06.041 Specified Answer for: f M06.042 Specified Answer for: g M71.342 Specified Answer for: h M80.08XD

CASE 9 Hospital Admission Chief complaint: Nausea and vomiting, weakness HPI: The patient is a 78-year-old Hispanic female with a history of diabetes, hypertension, and osteoporosis who was just discharged after hospitalization for gastroenteritis three days ago. She went home and was feeling fine, was tolerating regular diet until yesterday when she vomited. She stated she feels nauseated now, feels like she needs to throw up but cannot vomit. Her last bowel movement was yesterday. She stated it was diarrhea and states she has extreme weakness. No melena or hematochezia. No shortness of breath, no chest pain. Medical History: Diabetes mellitus type 2. Hypertension. Osteoporosis. Surgical History: None Medicines: Benadryl 25 mg daily, Diovan 320/25 one daily, calcium 600 daily, vitamin C 500 daily, multivitamin 1 tablet daily, Coreg CR 20 mg daily, Lipitor 20 mg at bedtime, metformin 1000 mg/day. Allergies: MORPHINE Social History: No tobacco, alcohol or drugs. She is a widow. She lives in Marta. She is retired. Family History: Mother deceased after childbirth. Father deceased from asphyxia. ROS: Negative for fever, weight gain, weight loss. Positive for fatigue and malaise. Ears, Nose, Throat: Negative for rhinorrhea. Negative for congestion. Eyes: Negative for vision changes. Pulmonary: Negative for dyspnea. Cardiovascular: Negative for angina. Gastrointestinal: Positive for diarrhea, positive for constipation, intermittent changes between the two. Negative for melena or hematochezia. Neurologic: Negative for headaches. Negative for seizures. Psychiatric: Negative for anxiety. Negative for depression. Integumentary: Positive for rash for which she takes Benadryl. Genitourinary: Negative for dysfunctional bleeding. Negative for dysuria. Objective: Vital signs: Show a temperature max of 98.1, T-current 97.6, pulse 62, respirations 20, blood pressure 168/65. O2 sat 95% on room air. Accu-Chek, 135. Generally: No apparent distress, oriented x 3, pleasant Spanish speaking female. Head, ears, eyes, nose, throat: Normocephalic, atraumatic. Oropharynx is pink and moist. No scleral icterus. Neck: Supple, full range of motion. Lungs: Clear to auscultation bilaterally. Cardiovascular: Regular rate and rhythm. No murmurs, gallops, rubs. Abdomen: Soft, nontender, nondistended. Normal bowel sounds. No hepatosplenomegaly. Negative Murphy's sign. Back: Costovertebral angle tenderness Extremeties: No clubbing, cyanosis or edema. Laboratory Studies. Shows a sodium 125, potassium 3.1, chloride 90, CO2 27, glucose 103, BUN 13, creatinine 0.7, white count 8.3, hemoglobin and hematocrit 12.6, 37.1, platelets 195, 000. Differential shows 76% neutrophils. Amylase 42, CK-MB 1.7, troponin 0.05, CPK 59. PTT 26.9. PT and INR 12.9 and 1.09. UA shows 500 leukocyte esterase, negative nitrite, 15 of ketones, 10 to 25 WBCs. Gallbladder sonogram shows a 1.24 x 1 cm echogenic focus in the gallbladder, possibly representing gallbladder polyp or gallbladder mass. CT abdomen and pelvis shows cholelithiasis, small left pleural effusion, small indeterminate nodules both lung masses, no acute bowel abnormality and sclerotic appearance of right greater trochanter, no free air. Assessment 1. Nausea, vomiting, diarrhea, likely gastroenteritis 2. Cystitis 3. Hypokalemia 4. Hyponatremia 5. Cholelithiasis 6. Diabetes mellitus type 2 7. Hypertension Plan: Will admit patient for IV hydration, add Levaquin 500 mg IV q 24 hours. Will add 20 mg KCl per L to IV fluid. Get a general surgery consult for cholelithiasis. Will check studies, fecal white blood cells, C. diff-toxin and fecal stool culture and sensitivity. What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM codes: [b], [c], [d], [e], [f], [g], [h], [i], [j]

Specified Answer for: a 99222 Specified Answer for: b R11.2 Specified Answer for: c R19.7 Specified Answer for: d N30.90 Specified Answer for: e E87.6 Specified Answer for: f E87.1 Specified Answer for: g K80.20 Specified Answer for: h E11.9 Specified Answer for: i Z79.84 Specified Answer for: j I10

CASE 6 Hospital progress note Subjective: Patient is without complaint. She states she feels much better. No vomiting or diarrhea. She did have bowel movement yesterday. No shortness of breath, no chest pain. The patient and daughter were questioned again about her cardiac history. She denies any cardiac history. She has no orthopnea, no dyspnea on exertion, no angina in the past and she has never had any heart problems in the past. Case discussed yesterday with Dr. Williams and I am waiting to find out on her surgery date. Objective: Vital Signs: Shows a T-max of 99.6, T-current 98, pulse 72, respirations 18. Blood pressure 154/65, 02 sat 96% on room air. Accu-checks, 113, 132, 96, 98. General: No apparent distress, oriented x 3, pleasant Spanish-speaking female. Head, Ears, Eyes, Nose, Throat: Normocephalic, atraumatic. Oropharynx pink and moist. Left eye has sclera erythema. Pupils equal, round, and reactive to light accommodation (PERRLA). Laboratory Data: Shows C Diff-toxin negative. Sodium 129, potassium 3.4, chloride 96, CO2 27, glucose 72, BUN 12, creatinine 0.6. Urine culture positive for E. coli, sensitive to Levaquin. Assessment: 1. Cholelithiasis 2. Cystitis 3. Conjunctivitis 4. Hyponatremia 5. Hypokalemia 6. Diabetes mellitus type 2 7. Hypertension If the patient is not to go to surgery today, will feed the patient and likely discharge her if she tolerates regular diet. Will add Norvasc 5 mg p.o. daily. Also pleural effusion, small. Will repeat a chest-x-ray PA and lateral this morning to evaluate that. What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM codes: [b], [c], [d], [e], [f], [g], [h]

Specified Answer for: a 99232 Specified Answer for: b K80.20 Specified Answer for: c N30.90 Specified Answer for: d H10.9 Specified Answer for: e E87.1 Specified Answer for: f E87.6 Specified Answer for: g E11.9 Specified Answer for: h I10

CASE 7 Discharge summary Hospital course: The patient was hospitalized two days ago with nausea and vomiting. She had an uneventful hospital course. She was diagnosed with cholelithiasis. General surgery was consulted. Dr. Williams thought this was perhaps causing her upper GI symptoms. She was scheduled for surgery on Monday. She was tolerating a regular diet. Her nausea and vomiting resolved and she desired to be dismissed home. She was found to have a bladder infection. She was started on Levaquin and she also had left eye conjunctivitis and she was given Clloxan eye ointment for that. Discharge Diagnoses: 1. Cholelithiasis 2. Cystitis 3. Conjunctivitis 4. Hyponatremia 5. Diabetes mellitus type 2 6. Hypertension Discharge Medications: 1. Levaquin 500 mg p.o. daily x2 days 2. Ciloxan ointment, apply b.i.d.to left eye x 4 days/ 3. Zofran 4 mg p.o. q. 4 hours p.r.n. nausea, vomiting #20 4. Benadryl 25 mg p.o. daily p.r.n. rash 5. Diovan 320 p.o. daily 6. Calcium 600 mg p.o. daily 7. Vitamin C 500 mg p.o. daily. 9. Metformin 1000 mg p..o. daily 10. Lipitor 20 mg p.o. at bedtime 11. Coreg CR 20 mg p.o. daily. Discharge Diet: Cardiac Activities: ad lib Discharge Instructions: Patient to be NPO after midnight Sunday. Dismiss: Home Condition: Good Follow-up: Follow-up with me in 1 week. Follow-up on Monday morning for cholecystectomy. NPO after midnight on Sunday. What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM codes: [b], [c], [d], [e], [f], [g], [h]

Specified Answer for: a 99238 Specified Answer for: b K80.20 Specified Answer for: c N30.90 Specified Answer for: d H10.9 Specified Answer for: e E87.1 Specified Answer for: f E11.9 Specified Answer for: g Z79.84 Specified Answer for: h I10

CASE 8 XYZ Nursing Home Subjective: The patient appears to be a little more altered than normal today. He is in some obvious discomfort. However, he is not able to communicate due to his mental status. Patient does appear fairly anxious. Physical Exam: Glucoses have been within normal limits. Patient has had poor p.o. intake, however, over the last 2-3 days. Temperature is 97, pulse is 79, respirations 20, blood pressure 152/92, and oxygen saturation 97% on room air. Patient can be aroused. Extraocular movements are intact. Oral pharynx is clear. Lungs are clear to auscultation bilaterally. Heart has a regular rate and rhythm. Abdomen is nontender and nondistended. Patient is able to move all extremities. He does have some mild pain over the apex of his right shoulder and bruising over the anterior lateral rib cage on the right side over approximately T8 to T10. No crepitus is noted. Patient indicates he hurts everywhere. Ancillary studies: A.M. labs - none new this morning. X-ray shows no evidence of fracture with definitive arthritis. Patient has chronic distention of bowels. This is always atypical exam. Telemetry shows no significant new arrhythmias. Assessment & Plan: 1. Patient is an 84-year-old Caucasian male who presented after a fall with rib contusion, right shoulder pain and uncontrolled pain since. He has been on Tramadol. However, I believe this is making him more altered. Thus, we will back off on medications and see if he comes back more to himself. We may try a different medication at a low dose later today if patient's mental status improves significantly. We will have patient out of bed three times a day. Physical therapy is working with the patient for significant deconditioning. 2. Patient with elevated blood pressures upon admission and still running a little bit high. Cardizem has been added to the medication regimen recently. We will follow this and see what it does for his blood pressure in the long run. He is in no immediate danger currently. 3. Very advanced dementia, will follow, continue on home medications. 4. Coronary artery disease and congestive heart failure. These appear stable at this time. 5. History of atrial fibrillation, sounds to be in regular rhythm currently and appears to be doing well on telemetry monitor. Again, Cardizem has been added for better control and blood pressure control. 6. Type 2 diabetes mellitus. Glycemic control has been good. However, patient has had poor p.o. intake over the last 2-3 days, which may be due to pain. Thus, we will hold glipizide for now to prevent hypoglycemia. 7. We will follow the patient closely and adjust medications as necessary. What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM codes: [b], [c], [d], [e], [f], [g], [h], [i], [j]

Specified Answer for: a 99309 Specified Answer for: b S20.211A Specified Answer for: c M25.511 Specified Answer for: d R03.0 Specified Answer for: e F03.90 Specified Answer for: f I25.10 Specified Answer for: g I50.9 Specified Answer for: h I48.91 Specified Answer for: i E11.9 Specified Answer for: j Z79.84

CASE 4 AGE: 33-year-old - Established patient VITAL SIGNS: TEMPERATURE: 98.9°F Tympanic, PULSE: 97 Right Radial, Regular, BP: 114/70 Right Arm Sitting, PULSE OXIMETRY: 98% , WEIGHT: 161 lbs. CURRENT ALLERGY LIST: LORTAB CURRENT MEDICATION LIST: LUNESTA ORAL TABLET 3 MG, 1 Every Day At Bedtime, As Needed PROZAC ORAL CAPSULE CONVENTIONAL 40 MG, 1 Every Day LEVOTHYROXINE SODIUM ORAL TABLET 100 MCG, 1 Every Day for thyroid MELOXICAM ORAL TABLET 15 MG, 1 Every Day for joint pain IMITREX ORAL TABLET 100 MG, 1 tab po as directed , can repeat after 2 hours for migraines, max 2 per day PHENERGAN 25 MG, 1 Every 4-6 Hours, As Needed for nausea CHIEF COMPLAINT: Here for a comprehensive annual physical and pelvic examination. (Patient is seen for a routine Pap smear and comprehensive physical exam. This will be a preventive visit.) HISTORY OF PRESENT ILLNESS: Pt here for routine pap and physical. Pt reports episode of syncope two weeks ago. Pt went to ER and had EKG, CXR and labs and says she was sent home and per her report everything was normal. She denies episodes since that time. She does occasionally have mild mid-epigastric discomfort but no breathing problems or light-headedness. Good compliance with her thyroid meds. (Discussion of meds for thyroid. This is not sufficient enough to bill a problem visit along with the preventive visit.) PAST MEDICAL HISTORY: Depression. FAMILY HISTORY: no cancer or heart disease, mother has hypertension. SOCIAL HISTORY: TOBACCO USE: Currently smokes 1 1/2 PPD, has smoked for 15 to 20 years. REVIEW OF SYSTEMS: Patient denies any symptoms in all systems except for HPI. PHYSICAL EXAM: (Comprehensive physical exam.) CONSTITUTIONAL: Well developed, well-nourished individual in no acute distress. EYES: Conjunctivae appear normal. PERLA ENMT: Tympanic membranes shiny without retraction. Canals unremarkable. No abnormality of sinuses or nasal airways. Normal oropharynx. NECK: There are no enlarged lymph nodes in the neck, no enlargement, tenderness, or mass in the thyroid noted. RESPIRATORY: Clear to auscultation and percussion. Normal respiratory effort. No fremitus. CARDIOVASCULAR: Regular rate and rhythm. Normal femoral pulses bilaterally without bruits. Normal pedal pulses bilaterally. No edema. CHEST/BREAST: Breasts normal to inspection with no deformity, no breast tenderness or masses.(Breast exam.) GI: Soft, non-tender, without masses, hernias or bruits. Bowel sounds are active in all 4 quadrants. GU: EXTERNAL/VAGINAL: Normal in appearance with good hair distribution. No vulvar irritation or discharge. Normal clitoris and labia. Mucosa clear without lesions. Pelvic support normal.(Thin prep Pap smear collection.) CERVIX: The cervix is clear, firm and closed. No visible lesions. No abnormal discharge. Specimens taken from the cervix for thin prep pap smear. UTERUS: Uterus non-tender and of normal size, shape and consistency. Position and mobility are normal.(Pelvic exam.) ADNEXA/PARAMETRIA: No masses or tenderness noted. LYMPHATICS: No lymphadenopathy in the neck, axillae, or groin. MUSCULOSKELETAL EXAM: Gait intact. No kyphosis, lordosis, or tenderness. Full range of motion. Normal rotation. No instability. EXTREMITIES: BILATERAL LOWER: No misalignment or tenderness. Full range of motion. Normal stability, strength and tone. SKIN: Warm, dry, no diaphoresis, no significant lesions, irritation, rashes or ulcers. NEUROLOGIC: CNs II-XII grossly intact. PSYCHIATRIC: Mood and affect appropriate. LABS/RADIOLOGY/TESTS: The following labs/radiology/tests results were discussed with the patient: Alb, Bili, Ca, Cl, Cr, Glu, Alk Phos, K, Na, SGOT, BUN, Lipid profile, CBC, TSH, PAP smear. ASSESSMENT/PLAN: UNSPECIFIED ACQUIRED HYPOTHYROIDISM What are the CPT® and ICD-10-CM codes reported? CPT® code: [a] ICD-10-CM codes: [b], [c], [d]

Specified Answer for: a 99395 Specified Answer for: b Z00.00 Specified Answer for: c Z01.419 Specified Answer for: d E03.9

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. Rationale: Coding acute and chronic conditions in ICD-10-CM follows the coding guidelines I.B.8. If the same condition is described as both acute (subacute) and chronic, and separate subentries exist in the Alphabetic Index at the same indentation level, code both and sequence the acute or (subacute) code first.

What ICD-10-CM code is reported for a routine exam when an abnormal finding is found?

Z00.01 Rationale: In the ICD-10-CM Alphabetic Index, look for Examination/medical (adult) (for) (of)/general (adult)/ with abnormal findings which directs you to Z00.01. Verify code selection in the Tabular List. When an abnormal finding is documented report an additional code to identify the abnormal finding.