Coding Corner Answer

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CPT Codes: 99213-25, 96374, J1740 x 3. Diagnosis: 733.00, 724.2

The level of the E/M visit is a level three. The history is at an expanded, problem-focused level:

• History of present illness was brief—duration, location, and associated signs and symptoms;
• The review of system was pertinent to the problem—musculoskeletal; and
• Past family and social history was not taken.

The exam was problem focused.

The medical decision making was at a moderate level:

• Number of diagnoses or treatment options was at a extensive level—established problem, worsening and a new problem with additional workup planned;
• Amount and/or complexity of data to be reviewed was at the minimal level—labs were ordered; and
• The complexity level was moderate—one or more chronic illnesses with mild exacerbation.

Only two out of three components are needed for an established patient visit. Because of this, the history and the medical decision making determined the level of this visit. A modifier -25 is also needed on the E/M code to show that it was a significantly separate need for the office visit.

The ibandronate sodium injection is coded 96374 because, as of January 1, 2009, the code was changed from 90774.

Visit www.rheumatology.org/practice for a complete list of 2009 drug administration code changes.