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- Filed under: Practice Management, THR Print, Department: Coding Corner
- Keywords: Evaluation and Management, Osteoarthritis, Coding, Billing, E&M
From: The Rheumatologist, September 2011
Coding Corner Answer
September’s Coding Answer
Answer: 99213
Diagnosis: 715.96
This is an established outpatient/office visit and should be coded as 99213 because it included:
- Expanded problem-focused history:
- History of present illness has five elements: location, duration, timing, severity, and context
- Review of system: one system reviewed—musculoskeletal
- Past, family, social history: Past medical history
- Expanded problem-focused examination:
- Four systems examined: constitutional, musculoskeletal, respiratory, and cardiovascular
- Straightforward decision making:
- One stable problem improving, moderate overall risk for prescription drug management, and no data were reviewed or ordered
