Coding Corner Answer

The diagnosis would be 443.0 and V71.89.

This encounter is coded as 99244 because it included:

Comprehensive history: extended history of present illness, complete review of symptoms, and complete past family and social history;
Comprehensive examination: eight systems (1995 exam utilized); and
Moderate complexity decision making: new problem with uncertain prognosis (primary or secondary Raynaud’s phenomenon); extensive laboratory studies ordered; prescription medication therapy initiated.

October’s Coding Answer

April’s Coding Answer

Teaching junior learners, such as medical students and residents, is increasingly important in rheumatology. Given the anticipated shortage of rheumatologists, attracting more trainees to our field and enhancing knowledge of the rheumatic diseases among physicians in other fields are critical to meeting the needs of our patients.1,2 In addition, clinical reasoning is a vital skill…

The levels of service within an evaluation and management (E/M) visit are based on the documentation of key components, which include history, physical examination and medical decision making. The history component is comparable to telling a story and should include a beginning and some form of development to adequately describe the patient’s presenting problem. To…

Coding Corner Answer

Coding Corner Answer: March 2008

Teaching Junior Learners in Rheumatology

How to Document a Patient’s Medical History

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