An established 43-year-old female patient diagnosed with rheumatoid arthritis in multiple joints comes to the office for her first infliximab infusion. The patient had routine labs, chest X-ray and tuberculin purified protein derivative test (PPD) two weeks prior to her office visit. The patient’s lab, chest X-ray and PPD results are reviewed. Her PPD and chest X-ray are negative. She denies any fevers, cough, dyspnea or concurrent illness. She is on a nonsteroidal antiinflammatory drug, weekly methotrexate subcutaneous injections, folic acid and ranitidine. No changes were made in the patient’s medications.
Her IV port is started at 10:00 a.m. and infliximab 200 mg infusion at 10:15 a.m., which was completed at 12:25 p.m. The patient’s weight is recorded at 135 lbs.
How would you code this patient encounter?