CPT: 99213, 89060
This is an established outpatient visit. The encounter is coded as 99213 because it included:
- History—Expanded problem-focused history. The history of present illness was brief, the review of systems was extended and the past medical and social history was documented.
- Examination—Detailed. There were seven organ systems examined. This makes the exam level detailed.
- Medical Decision Making—Low complexity. The number of problems was limited (established problem worsening), amount of data was minimal (labs) and the level of risk was moderate for prescription drug management. This makes the MDM low complexity.
Rationale for level three E/M visit: because the history was expanded problem focused, the exam was detailed and the MDM was low complexity. An established patient visit only needs two out of the three elements (history, examination and medical decision making) to determine the level of a visit.
The ICD-10 M10.072 documentation leads the decision tree to the answers below:
- Acute or chronic
- Idiopathic or drug induced or gout due to renal failure
- Anatomical site:
- Ankle and foot
For questions or additional information on coding and documentation guidelines, contact Melesia Tillman, CPC-I, CPC, CRHC, CHA, at firstname.lastname@example.org or 404-633-3777 x820.