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.