The visit would be considered established even though the patient has not seen this rheumatologist before; he is a partner to her physician. A patient is considered as an established patient if he or she is seen by anyone in the practice within three years. The visit would be considered as 99212 because the history and exam were problem focused and the medical decision making was of low complexity. You only need two out of three components for an established visit. A modifier -25 is needed on the office visit because it was separate and significant to the infusion.
The infusion of infliximab would be coded as 96413 one unit and 96415×2 because the infusion was two hours and thirty-eight minutes. The first hour is coded 96413, the second hour is coded as 96415, and, because the third hour was more than 31 minutes, it is qualified as a third hour and would be coded as 96415. The drug would be coded as J1745 with 60 units because this code is for 10 mg.