Date of service: 7/3/2019
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Explore This IssueAugust 2019
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A 66-year-old woman with age-related osteoporosis returns to the office for her third denosumab injection. Her last denosumab injection was on Feb. 5, 2019; she had rescheduled her last injection, because she was out of the country in January, when it was due. She is post-menopausal. Her last dual-energy X-ray absorptiometry (DXA) was done 12 months ago and showed that her bone mineral density was severely low, with a T score of -4.5.
The patient weighs 130 lbs.; her height is 5’6″. Her sitting blood pressure is 105/79, and her temperature is 98.1°F. The patient is in good spirits and aware of her surroundings. The registered nurse has prepared a single-use prefilled syringe containing a 60 mg solution of denosumab. The nurse administers the injection in the patient’s left upper thigh.
The patient tolerates the injection well. She is scheduled for a follow-up exam six weeks from today.
Diagnosis or impression: Severe post-menopausal osteoporosis.
How should this be coded?
Editor’s note: Coding Corner case vignettes presented are created to illustrate questions about coding. They are not intended to represent the full medical record of a case.