Coding Corner Answer

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November’s coding answer: 99245 Diagnoses: 791.0, 285.9, 782.1, 401.1, 784.0, V71.9

Justification: This encounter is an outpatient consultation because there is a formal consultation request from the patient’s primary care provider for a rheumatology evaluation and an opinion regarding the patient’s symptoms, and the rheumatologist provided a written report of her findings and plan to the patient’s primary care provider.

This was a high-complexity consultation because it included:

• Comprehensive history: Extended history of present illness, complete review of symptoms, and complete past, family, and social history;
• Comprehensive examination: 12 systems; and
• High-complexity medical decision making: Patient presenting with symptoms of a potentially life-threatening chronic illness; extensive laboratory studies ordered, MRI/MRA imaging with contrast ordered, and patient will be scheduled for renal biopsy; and treatments to be considered include parenteral drug therapy with significant risk of serious complications and morbidity.