AAPC Chapter 19

Mr. Yates 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. Yates. When EMS reached the hospital Emergency Department, Mr. Yates is in full arrest with torsades de pointes (ventricular tachycardia). Dr. H. Art spends another hour in critical care stabilizing the patient and performing CPR. The time the provider spent on CPR was 15 minutes (the CPR time was included in the one-hour critical care time). What are the appropriate procedure codes for this encounter?

. 92950, 99291, 99288 Rationale: Documentation describes physician direction of the paramedics (99288). In the CPT® Index look for Physician Services/Direction, Advanced Life Support. He spends another hour stabilizing the patient. Refer to the CPT® guidelines under Critical Care Services. The time for the CPR must be deducted from the 1 hour of critical care, making the critical care time 45 minutes, reported with critical care code 99291. CPR is not a service included in the critical care codes and may be reported separately with 92950. In the CPT® Index look for CPR (Cardiopulmonary Resuscitation).

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 these 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?

11300, D49.2, Z85.828

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) referring you to code 92950. Review code to verify accuracy. In the CPT® Index look for Catheterization/Central referring you 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 referring you to code 31500. Review code to verify accuracy.

NEW PATIENT OFFICE VISIT CHIEF COMPLAINT: Right inguinal hernia. HISTORY OF PRESENT ILLNESS: This 44-year-old athletic man has been aware of a bulge and a pain in his right groin for over a year. He is very active, both aerobically and anaerobically. He has a weight routine which he has modified because of this bulge in his right groin. Usually, he can complete his entire workout. He can swim and work without problems. Several weeks ago, in the shower, he noticed there was a bulge in the groin and he was able to push on it and make it go away. He has never had a groin operation on either side. The pain is minimal, but it is uncomfortable and it limits his ability to participate in his physical activity routine. In addition, he likes to do a lot of exercise in the back country and his personal physician, Dr. X, told him that it would be dangerous to have this become incarcerated in the back country. PAST MEDICAL HISTORY: Serious illnesses: Reactive airway disease for which he takes Advair. He is not on steroids and has no other pulmonary complaints. Operations: None. REVIEW OF SYSTEMS: He has no weight gain or weight loss. He has excellent exercise tolerance. He denies headaches, back pain, abdominal discomfort, or constipation. PHYSICAL EXAMINATION: VITAL SIGNS: Weight 82 kg, temperature 36.8, pulse 48 and regular, blood pressure 121/69. GENERAL APPEARANCE: He is a very muscular well-built man in no distress. SKIN: Normal. HEAD AND NECK: Sclerae are clear. External ocular eye movements are full. Trachea is midline. Thyroid is not felt. CHEST: Clear. HEART: Regular. ABDOMEN: Soft. Liver and spleen not felt. He has no abnormality in the left groin. In the right groin I can feel a silk purse sign, but I could not feel an actual mass. I am quite sure by history and by physical examination that he has a rather small indirect inguinal hernia. His cord and testicles are normal. NEURO: Grossly intact to motor and sensory examination. IMPRESSION: Right indirect inguinal hernia. PLAN: We discussed observation and repair. He is motivated toward repair and I described the operation in detail. I gave him the scheduling number and he will call and arrange the operation. What E/M code is reported?

99203 Rationale: New Patient Number and Complexity of Problems - One acute uncomplicated illness or injury - Low Amount and/or Complexity of Data to be Reviewed and Analyzed - None Medical decision making - elective major surgery, no identified risk factors - Moderate

CASE 2 The patient is a 32-year-old male here for the first time. (This is a new patient.) Chief Complaint: Left knee area is bothersome, (Chief complaint.) painful moderate severity. The patient also notes swelling in the knee area, limited ambulation, and inability to perform physical activities such as sports or exercises. The patient first noticed symptoms approximately 4 months ago. Problem occurred spontaneously. Problem is sporadic. 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. 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. Family History: Mother: No serious medical problems; Father: No serious medical problems. Social History: Patient is married. Occupation: Patient is a chef. 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. Review of Previous Studies: Patient brings an MRI which is reviewed. (The provider reviews a prior MRI.) Large knee effusion. No lateral meniscal tear. No ACL/PCL tear. No collateral fracture. Medial meniscus tear with grade I signal. Vitals: Height: 6'0", Weight: 160 Physical Examination: Patient is alert, appropriate, and comfortable. Patient holds a normal gaze. Pupils are round and reactive. Gait is normal. Skin is intact. No rashes, abrasions, contusions, or lacerations. No venous stasis. No varicosities. Reflexes are normal patellar. No clonus. Knee: Range of motion is approximately from 5 to 100 degrees. Pain with motion. No localized pain. Negative mechanical findings. There is an effusion. (Effusion is collection of fluid around the knee.) Patella is tracking well. No tenderness. Patient feels pain especially when taking stairs or squatting. Pain is a symptom of the final diagnoses and is not reported separately.) 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. Neck: Neck is supple. No JVD. Impression: 1. Infective synovitis of the left knee 2. Contracture of the left knee 3. Possible medial meniscal tear of right knee (This is an undiagnosed new problem. More testing is required to determine the extent of the injury.) Assessment and Plan: A discussion is held with the patient regarding his condition and possible treatment options. Patient has GI upset. (GI update is taken into consideration when providing a plan, although there are no details provided to expand on that or to report it as an additional diagnosis.) Patient is recommended to take Motrin 400 two to three times a day (Over the counter (OTC) medication.), discussion is held regarding proper use and precautions. Patient is given a prescription for physical therapy. Physical therapy ordered.) We will obtain an MRI (MRI ordered.) to rule out potential medial meniscus tear. Patient is instructed to follow up with PMD with labs. (No indication the labs were ordered or reviewed at this encounter.) Patient is referred to Dr. XYZ. Patient may need arthroscopy if patient does have medial meniscus tear and repeat effusion. (Plan for future encounters but not addressed during this encounter.) What are the CPT® and ICD-10-CM codes reported?

99203, M65.162, M24.562

CASE 5 NEW PATIENT OFFICE VISIT (This is a new patient.) CHIEF COMPLAINT: Right lower quadrant abdominal pain. (Chief complaint.) HISTORY OF PRESENT ILLNESS: The patient is a 67-year-old who presents with diffuse right lower abdominal pain. (Specificity of the location of the pain, which is required for the diagnosis.) The pain tends to be located near his right groin. He states that it has been present since the summer of 20XX. He was doing some significant activity at that time, including significant manual labor in his yard. It was at that time that he began to notice the symptoms. He continued to work in construction throughout the summer and fall. His symptoms continued through this time and only recently, as he has limited his activity, has the pain improved. He does not have any obstructive symptoms. He has not had previous inguinal hernia repair. He was seen by his primary care provider who thought he may have a spigelian type hernia and thus he has been sent to my clinic for evaluation of this problem. PAST MEDICAL HISTORY: Low back pain, osteoarthritis, hypertension, and anxiety. PAST SURGICAL HISTORY: Anal fistulotomy, appendectomy, patent foramen ovale closure, multiple arthroscopies, carpal tunnel release bilaterally, hand surgery for tendon releases, and bilateral cataract extraction. ALLERGIES: He gets nausea and vomiting with narcotics, but otherwise has no true medication allergies. CURRENT MEDICATIONS: Clonazepam, AndroGel, multivitamins. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: The patient is retired. He tries to exercise regularly. He does not smoke or drink. REVIEW OF SYSTEMS: An 11-point review of systems was undertaken and, except for some mild upper respiratory tract infection type symptoms and some low back pain, was essentially negative. PHYSICAL EXAMINATION: Vital Signs: Temperature is 96.4. Heart rate is 72. Blood pressure is 164/92. Respiratory rate is 15. Height is 5 feet 0 inches. Weight is 199 pounds. HEENT: The sclerae are anicteric and the oropharynx is clear. Neck: No jugular venous distension or lymphadenopathy. Chest: Clear to auscultation bilaterally. Cardiac: Regular rate without murmurs. Abdomen: Soft, nontender, and nondistended with no palpable intraabdominal abnormalities of note. Specifically, there are no palpable anterior abdominal wall fascial abnormalities of note. Back: No CVA tenderness and no spinal abnormalities. Groin: Both the right and left inguinal regions are intact with no evidence of hernia. There are no spermatic cord or testicular abnormalities. Extremities: No clubbing, cyanosis, or edema. ASSESSMENT: Right groin pain, improving with limitation of activity. PLAN: This patient most likely has one of two issues that are responsible for his symptoms. (Although the provider has two differential diagnoses, neither is at a high risk of morbidity.) One would be an occult hernia on the right side. This would present with pain without a palpable hernia on examination. This is where the posterior wall is disrupted and can lead to the same symptoms as an inguinal hernia, but without a palpable hernia. In this situation, patients typically do not get very much relief of their symptoms by decreasing their activity as one is continually utilizing the abdominal wall musculature and remain symptomatic from the hernia. Treatment would require laparoscopic surgery. (Possible surgical treatment option.) The other possible pathology would be an abdominal wall injury such as a muscle pull or strain. This typically would get better with rest and since the patient is stating that his symptoms have improved over the last month or so with decreasing his activity then I would expect that he would continue to improve with conservative management. The patient agrees with the plan of continued decreased activity for the next four to eight weeks. (Conservative treatment if rest is chosen.) He has not had any projects planned around his house and is not going to participate in construction at this time. He will get back to his normal activity in March. He will pay attention to his symptoms and if he does have recurrence of his symptoms with increasing physical activity, he will contact my office to arrange follow-up. What are the CPT® and ICD-10-CM codes reported?

99203, R10.31

New Patient History & Physical CHIEF COMPLAINT: Right chronic inguinal hernia. HISTORY OF PRESENT ILLNESS: This 44-year-old athletic man has been aware of a bulge and a pain in his right groin for over a year. He is very active, both aerobically and anaerobically. He has a weight routine which he has modified because of this bulge in his right groin. Usually, he can complete his entire workout. He can swim and work without problems. Several weeks ago in the shower he noticed there was a bulge in the groin and he was able to push on it and make it go away. He has never had a groin operation on either side. The pain is minimal, but it is uncomfortable and it limits his ability to participate in his physical activity routine. In addition, he likes to do a lot of exercise in the back country and his personal provider, Dr. X told him it would be dangerous to have this become incarcerated in the back country. PAST MEDICAL HISTORY: Serious illnesses: Reactive airway disease for which he takes Advair. He is not on steroids and has no other pulmonary complaints. Operations: None. MEDICATIONS: Advair. ALLERGIES: None. REVIEW OF SYSTEMS: He has no weight gain or weight loss. He has excellent exercise tolerance. He denies headaches, back pain, abdominal discomfort, or constipation. PHYSICAL EXAMINATION: VITAL SIGNS: Weight 82 kg, temperature 36.8, pulse 48 and regular, blood pressure 121/69.GENERAL APPEARANCE: He is a very muscular well-built man in no distress. SKIN: Normal. LYMPH NODES: None. HEAD AND NECK: Sclerae are clear. External ocular eye movements are full. Trachea is midline. Thyroid is not felt. CHEST: Clear to auscultation. HEART: Regular rhythm with no murmur. ABDOMEN: Soft. Liver and spleen not felt. He has no abnormality in the left groin. In the right groin I can feel a silk purse sign, but I could not feel an actual mass. I am quite sure he has by history and by physical examination a rather small indirect inguinal hernia. His cord and testicles are normal. IMPRESSION: Right chronic indirect inguinal hernia. PLAN: We discussed observation and repair. He is motivated toward repair and I described the operation in detail. He was cautioned on the fact this could become an emergent situation if this becomes incarcerated. I gave him the scheduling number, and he will call and arrange the operation. What CPT® and ICD-10-CM codes are reported?

99204, K40.90 Rationale: This is a new patient office visit which is coded from range 99202-99205. Medical decision making is the determining factor for selecting E/M level with 2021 guidelines for Office and Other Outpatient Services and requires all three elements to be met or exceeded for a new patient. A chronic condition with exacerbation (Moderate). No data to review (None). Elective major surgery without risk factors (Moderate risk). MDM is moderate reporting 99204.In the ICD-10-CM Alphabetic Index look for Hernia, hernial/inguinal (indirect). Indirect is a nonessential modifier listed for Hernia, hernial/inguinal. You are directed to K40.90. Verify code in the Tabular List.

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.

99213 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. The provider suspects the patient's swelling is a result of the pulmonary hypertension. It is not confirmed at this time, but it is something the provider is going to investigate further. This is considered an acute illness with systemic symptoms (Moderate-Number and complexity of problems addressed). Provider reviews labs and an echocardiogram and orders a sleep study. This is a follow up condition because there is no documentation to indicate the labs and echocardiogram were ordered by this provider or another provider there is no credit given for these tests. The provider does order one unique test [the sleep study] (Minimal- Amount and complexity of data to be reviewed and analyzed). Further study (sleep study test) is needed to determine the cause of the pulmonary hypertension. The level of risk is based on how the condition was treated/managed by the provider. There is low risk involved with a sleep study. (Low- Risk of complications and morbidity or mortality of patient management)

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 medically appropriate history and exam. Abdominal ultrasound is ordered and 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?

99213, K37, R12 Rationale: This is an established patient due to the indication she returning to her provider for the visit. Medical decision making is the determining factor for the level with 2021 E/M guidelines for Office and Other Outpatient services. Acute uncomplicated illness (Low), order of the ultrasound (Minimal), and prescription management (moderate risk). Low medical decision making supports 99213.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.

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. (Although dyslipidemia and chronic pain are listed as a history, there is no documentation to support the conditions were treated at this encounter or that they affected the management of the current conditions. These conditions are not coded and are not taken into consideration for the level of medical decision making.) The patient is here for follow-up of bilateral lower extremity swelling. The patient tells me that the swelling responded to hydrochlorothiazide. 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, (Labs were reviewed; however, the labs are credited at the time the labs were ordered. No credit given for MDM.) and echocardiogram. (An echocardiogram is reviewed. The echocardiogram is credited at the time it was ordered. No credit given for MDM.) The patient does have moderate pulmonary hypertension. ASSESSMENT: 1. Bilateral lower extremity swelling: Improved with diuretics; this may be secondary to problem #2. (The extremity swelling is possibly due to pulmonary hypertension, but not certain, so it is coded separately for the diagnosis. Acute illness with systemic symptoms.) 2. Pulmonary hypertension: Etiology is not clear at this time, will do a workup 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. (A sleep study is ordered.) What are the CPT® and ICD-10-CM codes reported?

99213, M79.89, I27.20 : CPT® code: Subcategory — Office visit, established patient, coded using 2021 E/M guidelines Number and complexity of problems addressed: Pulmonary hypertension can be a serious condition. The provider suspects the patient's swelling is a result of the pulmonary hypertension. It is not confirmed at this time, but it is something the provider is going to investigate further. This is considered an acute illness with systemic symptoms, making this moderate for the number and complexity of problems addressed. Amount and complexity of data to be reviewed and analyzed: In this case, the provider reviews labs and an echocardiogram, and orders a sleep study. Because this is a follow up patient and a follow up condition, and there is no indication the labs and echocardiogram were ordered by another provider, there is no credit given for these. The provider orders one unique test (the sleep study), making this Minimal for the amount and complexity of data to be reviewed and analyzed. Risk of complications and morbidity or mortality of patient management: Further study (additional testing) is needed to determine the cause of the pulmonary hypertension. There is low risk involved in a sleep study. The risk associated with the problem of pulmonary hypertension was given in the number and complexity of problems addressed. The risk of patient management is low.

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 last year. 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?

99213-25, 20612-F1, 77080, J1020, M06.041, M06.042, M71.342, M80.08XD

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. Exam was performed. Provider reviewed the complete blood count lab from the hospital and personally viewed and interpreted a recent chest X-ray that shows the right lung with infiltrates. 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?

99214 Rationale: The patient was seen in the clinic which is an outpatient service. Medical decision making is the determining factor for selecting E/M level with 2021 guidelines for Office and Other Outpatient services. Number and Complexity of Problems Addressed is Moderate for an acute illness with systemic symptoms (Moderate). The pneumonia is still being treated and is considered as acute. Data Reviewed and Analyzed includes a review of lab from the hospital and independent visualization of the chest X-ray (Moderate). Prescription drug management (Moderate risk). MDM is moderate reporting 99214.

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 medically appropriate history and exam. Medical decision making is 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?

99215, R55 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. A medically appropriate history and exam are documented. MDM is of high complexity. Based on 2021 E/M guidelines for Office and Other Outpatient services, this supports 99215.

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.

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, alert and 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?

99222, R11.2, R19.7, N30.90, E87.6, E87.1, K80.20, E11.9, Z79.84, 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?

99232, K80.20, N30.90, H10.9, E87.1, E87.6, E11.9, I10

A 33-year-old male was admitted to the hospital on 12/17/XX from the ER following a motor vehicle accident. His spleen was severely damaged and a splenectomy was performed. The patient is being discharged from the hospital on 12/20/XX. During his hospitalization the patient experienced pain and shortness of breath, but with an antibiotic regimen of Levaquin, he improved. The attending provider performed a final examination and reviewed the chest X-ray revealing possible infiltrates and a CT of the abdomen ruled out any abscess. He was given a prescription of Zosyn. The patient was told to follow up with his PCP or return to the ER for any pain or bleeding. The provider spent 20 minutes on the date of discharge. What CPT® code is reported for the 12/20 visit?

99238 Rationale: The patient is being discharged from the hospital. Hospital discharge codes are determined based on the time documented the provider spent providing services to discharge the patient. The provider documented 20 minutes which is reported with 99238.

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?

99238, K80.20, N30.90, H10.9, E87.1, E11.9, Z79.84, I10

The attending provider at the hospital spent 25 minutes with the patient in the morning and another 15 in the afternoon examining the patient, writing discharge orders and giving discharge instructions to the patient. What CPT® code is reported for the discharge?

99239 Rationale: In the CPT® Index look for Hospital Services/Inpatient Services/Discharge Services and you are directed to code ranges 99238-99239 and 1110F-1111F. Codes 1110F-1111F are Category II supplemental codes used for performance measurement. They may not be used as a substitute for Category I codes. Codes 99238-99239 are based on time. All of the time spent by the discharge provider on the discharge date is included in the time. The provider spent a total of 40 minutes with the patient on the discharge date. 99239 is the correct code choice.

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 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 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.

Patient is seen in the ED for a migraine. She is experiencing nausea with vomiting and decreased appetite. Blurry vision. Has had a low-grade fever. The pain is rated 9 out of 10 and is not responding to oral medication. Physical exam: General appearance: Mild distress. 99.6 BP 110/60 Resp 18Skin: Warm. Dry. No pallor. No rash. Good skin turgor. Facial: No bruises, no swelling, no tenderness.Scalp: No swelling, no deformity, no tenderness. Neck: Trachea midline.Cognitive function: Within normal limits.Best response: Within normal limits.Speech: Within normal limits.Sensation: Within normal limits. Motor strength: Within normal limits.Extinction-neglect: Negative.Reflexes: Within normal limits.Cerebellar test: Within normal limits. Assessment: Migraine headache - intractable, R/O viral infection, meningitis Plan: She will be admitted. Order CT of head and lumbar puncture. What E/M code is reported?

99283 Rationale: For an emergency visit, all three key components must be met: History—HPI (Brief), ROS (Extended), PFSH = Expanded Problem Focused Exam—Detailed (extended exam of constitutional, skin, neck, neurologic) MDM—Moderate for (new problem to examiner with additional work-up [additional tests were ordered to rule out meningitis]; order of radiology test (1 point); level of risk moderate [lumbar puncture] The documentation supports 99283.

The EMS brought a 31-year-old motor vehicle accident patient to the Emergency Department. After a comprehensive history, a comprehensive exam and medical decision making of high complexity, the provider determines the patient has multiple internal injuries and needs immediate surgery. What level ED code is reported?

99285 Rationale: In the CPT® Index look for Evaluation and Management/Emergency Department. The code range is 99281-99288. All three key components must be met in order to reach the level of visit. A comprehensive history, comprehensive exam and medical decision making of high complexity supports a level 5 ED visit, 99285.

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 failure Community acquired pneumonia Septic shock Non-oliguric acute renal failure PLAN: 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 minutes What 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.

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?

99309, S20.211A, M25.511, R03.0, F03.90, I25.10, I50.9, I48.91, E11.9, Z79.84

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.

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?

99395, Z00.00, Z01.419, E03.9

A 75-year-old established patient sees his regular primary care provider for a physical screening prior to joining a group home. He has no new complaints. The patient has an established diagnosis of cerebral palsy and type 2 diabetes and is currently on his meds. A comprehensive history and examination is performed. The provider counsels the patient on the importance of taking his medication and gives him a prescription for refills. Blood work was ordered. PPD was done and flu vaccine given. Patient already had a vision exam. No abnormal historical facts or finding are noted. What CPT® code is reported?

99397 Rationale: According to CPT® guidelines Preventive Medicine Services codes provide a means to report a routine or periodic history and physical examination in asymptomatic individuals. They include only those evaluation and management services related to the age specific history and examination provided by the provider. The patient is here for a preventive service. He did not have any complaints and the provider did not identify any new problems. In the CPT® Index look for Preventive Medicine/Established Patient. You are referred to 99382-99397. The code selection is based on age. Code 99397 is the correct code for a patient who is older than 65 years.

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.

Physical Exam: GENERAL APPEARANCE: Healthy appearing individual in no distress ABDOMEN: Soft, non-tender, without masses. No CVA tenderness FEMALE EXAM: VULVA/LABIA MAJORA: No erythema, ulcerations, swelling, or lesions seen. BARTHOLIN GLANDS: No cysts, abscesses, induration, discharge, masses, or inflammation noted. SKENE'S: No cysts, abscesses, induration, discharge, masses, or inflammation noted. CLITORIS/LABIA MINORA: Clitoris normal. No atrophy, adhesions, erythema, or vesicles noted. Labia unremarkable. URETHRAL MEATUS: Meatus appears normal in size and location. No masses, lesions or prolapse. URETHRA: No masses, tenderness or scarring. BLADDER: Without fullness, masses or tenderness. VAGINA: Mucosa clear without lesions, Pelvic support normal. No discharge. CERVIX: The cervix is clear, firm and closed. No visible lesions. No abnormal discharge. UTERUS: Uterus non-tender and of normal size, shape and consistency. Position and mobility are normal. ADNEXA/PARAMETRIA: No masses or tenderness noted. Based on the 1995 documentation guidelines, what is the level of exam?

Comprehensive Rationale: Organ Systems: The documentation supports a comprehensive/complete single system (Female Genitourinary) exam. 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's 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.

Emergency DepartmentA 47-year-old white male presents to the emergency department after the four-wheeler he was operating struck a ditch and rapidly came to a halt. This threw him against the windshield where he struck the mid part of his face and lower lip. This resulted in lip and chin lacerations. He is evaluated by Dr. Jones and a CT scan suggests a hyper dense abnormality within the brain. A bleed could not be ruled out and an inpatient hospital admission is recommended. His past history includes previous tonsillectomy, previous hospital admission for a syncopal episode associated with pain in the groin area, and hypercholesterolemia. He has no known allergies. His current medications are Zocor® and Accutane®. He is a non-smoker and a moderate drinker of alcohol.The review of systems is negative for nausea, vomiting, blurred vision, or headache. What is the level of history?

Expanded problem focused

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

I20.1 Rationale: Look in the ICD-10-CM Alphabetic Index for Angina (attack) (cardiac) (chest) (heart) (pectoris) (syndrome) (vasomotor)/with/documented spasm referring you to I20.1. Verify code selection in the Tabular List.

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.

IMPRESSION: Right recurrent gynecomastia. PLAN: The patient is sent for consultation re: right breast ultrasound performed by PCP. Review of the films show a hypoechoic area measuring 1.7 x 0.7 x 1.2 cm in the 11 o'clock position of the right breast. There was no Doppler flow, and the transmission suggested that this was a cystic lesion. Her gyn requested a consultation. Because of this ultrasound and because this is symptomatic, I have recommended a simple mastectomy under general anesthesia. The patient agrees. I described the operation to the patient. What is the level of medical decision making?

Moderate Rationale: New problem to examiner, no additional workup (three points); ultrasound reviewed (one point); moderate level of risk (simple mastectomy). The medical decision-making is Moderate.

Hospital visit CHIEF COMPLAINT: Gallstones and reflux. HISTORY OF PRESENT ILLNESS: This is a 61-year-old woman who was seen in the ER and subsequently admitted in observation status. She has a two-year history of severe gallbladder attacks. Also of note, she has had ongoing reflux problems for many years. Within the last few months, her reflux has worsened. ASSESSMENT/PLAN: This is a 61-year-old woman with symptomatic cholelithiasis and reflux. Her number one concern right now is the gallbladder pain. This sounds like symptomatic cholelithiasis. As a result, we will schedule her for laparoscopic cholecystectomy with intraoperative cholangiogram. The risks and benefits were explained to the patient who understood and agrees for us to proceed. With regards to her reflux, it is partially controlled by her medication. She also is overweight and might have symptom improvement after weight loss. She is also very hesitant to proceed with the Nissan fundoplication because her husband had the surgery done before and had some problems with vomiting afterwards. She does have objective evidence of reflux as well and is a good candidate for surgery. However, we will let her decide whether she wants to proceed with this procedure. What is the level of medical decision making?

Moderate Rationale: Two problems worsening (4 points). No data reviewed with moderate level of risk (elective major surgery). The medical decision making is Moderate.

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.

What category of codes should be used to report an evaluation and management service provided to a patient in a psychiatric residential treatment center?

Nursing facility services Rationale: The guidelines for Nursing Facility Services state, "These codes should also be used to report evaluation and management services provided to a patient in a psychiatric residential treatment center."

During a soccer game, Ashley, a 26-year-old female, heard a popping sound in her knee. Her knee has been unstable since the incident and she decided to consult an orthopedist. She visits Dr. Howard, an orthopedist she has not seen before, to evaluate her knee pain. Dr. Howard's diagnosis is a torn ACL. From what category or subcategory of evaluation and management code would be selected for the visit to Dr. Howard?

Office visit, new patient Rationale: Consultations performed at the request of a patient are coded using office visit codes. Because the patient has not seen Dr. Howard before, this would be considered a new patient visit.

The patient is seen in the nursing home today for a follow up of his hospitalization for pneumonia. He was placed back on Singulair® and has been improving with his breathing since then. What is the level of history?

Problem focused

If the pain is sharp, stabbing or dull, using the 1995 & 1997 guidelines, what is the component of the History of Present Illness (HPI)?

Quality Rationale: Quality describes a problem's characteristics. Sharp, stabbing or dull refer to the characteristics of pain.

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.