CPT: 99213, 73500-RT, 73500-LT
This E/M service entailed:
- The history is detailed;
- The examination is expanded problem focused; and
- The medical decision making is of low complexity.
The X-ray reviewed was for radiologic examination, hip, unilateral: one view for the left hip and for the right hip.
M16.52—The diagnosis identifies unilateral post-traumatic osteoarthritis of the left hip.