Coding Corner Answer

CPT Code: 99221 Diagnosis: 714.0, V43.65

Detailed history:
- Detailed history of present illness: location, modifying factor, associate sign and symptoms, and timing;
- Extended: musculoskeletal, constitutional; and
- Past family social history: has not changed since the patient was last seen by the rheumatologist.
Detailed examination:
- Five systems: constitutional, respiratory, cardiovascular, gastrointestinal, and musculoskeletal.
Straightforward decision making:
- RA is stable;
- Recovery from the surgical procedure is underway; and
- Prescription drug management.

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