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You are here: Home / Articles / Coding Corner Question: April

Coding Corner Question: April

April 1, 2015 • By From the College

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A 60-year-old female is seeing a rheumatologist for the first time. She was referred by her primary care physician (PCP) for postmenopausal osteoporosis. She complains of back pain when she sits for a long period of time, and the severity of the pain is a level 7 out of 10. Because of the pain, she is not as mobile as she would like to be, so she has gained at least 15 lbs. since her last visit to her PCP. She had a pathological fracture of her left hip that occurred two years ago, which has healed completely. She is a nonsmoker, and her mother, who recently passed away, also had osteoporosis.

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Her vitals: weight 138 lbs., blood pressure 115/86, temperature 98ºF. The patient appears to be in a good mood and is aware of her surroundings. The patient has a profound stooped posture, and her gait is slightly off center. Her RRR is WNL. The auscultation of her lungs is normal. She shows no shortness of breath.

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As part of her workup, a dual-energy X-ray absorptiometry (DXA) scan is needed. Her last DXA was ordered more than two years ago by her PCP. A bone density study of her axial skeleton is performed, including a vertebral fracture assessment. She is scheduled for a follow-up visit in four weeks.

How would you code this patient encounter? Click here for the answer.

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Filed Under: Billing/Coding, From the College, Osteoarthritis, Practice Management Tagged With: Billing, Coding, dual-energy x-ray absorptiometry, DXA, Osteoarthritis, rheumatology, scanIssue: April 2015

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