A 73-year-old female established patient with rheumatoid arthritis affecting multiple joints and with positive rheumatoid factor returns to the office for an infliximab infusion.
She denies any fevers, cough, dyspnea or concurrent illness. She has joint pain of 6 on the pain scale. She is on an NSAID, weekly methotrexate subcutaneous injections, folic acid and ranitidine. No changes were made in the patient’s medications. The patient weighs 130 lbs., and her past family and social history has not changed since it was taken six months ago.
She was administered 50 mg of diphenhydramine intravenously over two minutes as a prophylactic measure against a drug reaction to the infliximab. Her IV started at 10:00 a.m., and the intravenous infliximab 300 mg was infused from 10:15 a.m. until 12:28 p.m.
How should this encounter be coded?