Answer
CPT code: 99214
Diagnosis: ICD-9 274.02 or ICD-10 M1A.2720, T50.4X1D
History—The history of present illness was extended. The review of systems was extended (six systems were reviewed), and two of the three elements for past family social history were documented. This makes the history level detailed.
Examination—There were four systems examined. This makes the exam expanded-problem focused.
Medical decision making—The number of diagnosis was for an established problem that was worsening, which is limited. The amount of data was limited. The level of risk was moderate for prescription drug management. This makes the medical decision making low complexity.
Please note: The documentation of the history, exam and medical decision making would normally make this a level 3 visit (99213). Because time and the discussion were documented and more than 50% of the visit was spent with the patient face to face, time is the key factor in determining the level of this visit. CPT states that an established patient level 4 visit is typically 25 minutes long, and this visit was 33 minutes long and qualifies to be coded as a level 4 (99214).
ICD-9 274.02—Chronic gouty arthropathy without mention of tophus (tophi).
ICD-10 M1A.2720—Drug-induced chronic gout, left ankle and foot, without tophus (tophi). According to ICD-10 coding guidelines, if a diagnosis is listed from the drug-induced gout category, then an additional code to identify the drug is required from the Drugs and Chemical Table.
T50.4X1D—Poisoning by drugs affecting uric acid metabolism, accidental (unintentional), subsequent encounter.
