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A 66-year-old female patient returns for a second infusion of rituximab for her diagnosis of rheumatoid arthritis in multiple sites. She is rheumatoid factor positive. She says the pain in her knees, elbows and neck has slightly improved. She rates the severity of her pain at a 7 on a 10-point scale, which is an improvement from the 8 she reported during her last visit. The patient is currently on 7.5 mg methotrexate by mouth weekly. She reports no fevers, headaches, chest pain, dyspnea, cough, oral ulcers, rashes or depression.
Infusion note: The patient’s blood pressure is 125/88, height is 5’6”, weight is 225 lbs., body mass index is 36.3, and temperature is 97°F.
Diagnosis: Rheumatoid arthritis of multiple joints, rheumatoid factor positive.
Her IV is started with 150 cc of normal saline solution and 500 mg of rituximab is prepared for the infusion, and 40 mg of methylprednisolone sodium succinate is pushed into the patient’s IV. The rituximab infusion is started at 9:05 a.m. and slow dripped until 1:12 p.m. The patient is observed for 15 minutes and instructed to make a follow-up appointment and return to the office in four weeks.
How is this visit billed?
Editor’s note: Case vignettes presented in the Coding Corner are created to illustrate questions about coding. They are not intended to represent the full medical record of a case.