A 43-year-old established female patient diagnosed with rheumatoid arthritis comes to the office for her first infliximab infusion.
The patient had routine labs, a chest X-ray, and a tuberculin purified protein derivative (PPD) test three days ago. The rheumatologist reviewed the patient’s lab results, chest X-ray, and PPD site. The PPD and chest X-ray are negative, but the patient still has pain, stiffness, and swelling in her elbows, wrists, and most finger joints. She denies any fevers, cough, dyspnea, or concurrent illnesses. She is on a nonsteroidal antiinflammatory drug, weekly methotrexate subcutaneous injections, folic acid, and ranitidine.
The rheumatologist performs an expanded, problem-focused exam, and no changes are made in the patient’s medications.
The patient’s IV port is started at 9:45 AM. The medication of IV infliximab 200 mg infusion is started at 10:15 AM and is completed at 12:25 PM.
How would you code this patient encounter?