CPT codes: 99203-25, 77085
You Might Also Like
Explore This IssueApril 2015
Also By This Author
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.