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You are here: Home / Articles / Coding Corner Answer

Coding Corner Answer

September 1, 2008 • By From the College

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September’s coding answer: This visit would be considered not medically necessary because nowhere

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in the notes does the rheumatologist acknowledge that he took the history of present illness (HPI).

The notes state that the patient reports the HPI to the nurse, not the physician.

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Below is what the visit could have been coded had the HPI been taken by the physician:

This is an established patient outpatient/office visit and should be coded as 99213 because it included:

  • Expanded, problem-focused history: HPI has six elements; review of systems pertinent to problem; past family and social history is not addressed;
  • Detailed examination: five systems; and
  • Straightforward decision making: One stable problem improving, moderate risk for prescription drug management, no diagnostic studies ordered.

The diagnosis should be coded as 715.36

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Filed Under: Billing/Coding, From the College, Practice Management Tagged With: Billing, Coding, Diagnosis, OsteoarthritisIssue: September 2008

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