Coding Corner Answer: October Coding Challenge

CPT codes: 99214-25, 20610-RT, 76942-RT, J7325 x 20

ICD-9 codes: 715.96, 787.02

ICD-10 codes: M17.9, R11.0, E66.9, Z68.41

This encounter is coded as 99214 because it included:

Detailed history—extended history of present illness, extended review of systems, one past family and social history;
Comprehensive examination—eight systems; and
Medical decision making—moderate complexity (established problem worsening, new problem with additional workup [the injection]; prescription drug management).

The CPT code 20610 is for the intraarticular injection of the right knee.

The use of CPT code 76942 is medically necessary because of the diagnosis of obesity, E66.9, and the documentation of the BMI, which took into account the patient’s age and BMI level, Z68.41.

This is an example of documentation needed for ICD-10 diagnosis coding.

The ICD-10 page on the Centers for Medicare & Medicaid Services (CMS) website features a countdown clock that shows the time left until Oct. 1, 2015, the date on which compliance with the new code set becomes mandatory. By the time this issue goes to press, the clock will read 90 or fewer days. Time…

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