Coding Corner Answer: April

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CPT codes: 99203-25, 77085

ICD-9: 733.01, V13.51
ICD-10: M81.0, Z87.310

This encounter is coded as 99203 because it included:

Detailed history—history of the present illness is extended; the review of systems is extended, and the past family social history is complete;
Detailed exam—five systems were examined (constitutional, musculoskeletal, respiratory, cardiovascular and psych); and
Moderate medical decision making. As of January 2015, CPT updated the DXA, bone density study codes 77080–77086.
77085 axial skeleton (e.g., hips, pelvis, spine), including vertebral fracture assessment

The ICD-10 code is M81.0, which indicates that this is age-related osteoporosis without current pathological fracture. The code Z87.310 is for the personal history of osteoporosis fracture.

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