Coding Corner Answer: September’s Coding Challenge

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CPT Code: 99221

Diagnosis: 714.0

Detailed history:

• Brief history of present illness—location, modifying factor, severity, and quality.
• Problem-pertinent review of systems—musculoskeletal.
• Past family and social history was not documented.
• Detailed examination:
• Five systems—constitutional, respiratory, cardiovascular, gastrointestinal, and musculoskeletal.
• Straightforward decision making:
• Rheumatoid arthritis was stable.
• Recovering from surgical procedure.