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CPT: 99214-25, 89060, 20600-RT
ICD-10: M10.271, T50.2X5A, I10
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This is an established outpatient visit. This encounter is coded as 99213, because it included:
- History—Detailed: The history of present illness is extended, the review of systems is extended, and the past medical and social histories are documented.
- Examination—Detailed: Seven organ systems are examined.
- Medical decision making—Moderate complexity: The number of problems includes one established problem, stable; and one established problem, worsening. The amount of data is minimal (labs), and the level of risk is moderate for acute illness with systemic symptoms.
This is a level-three E/M visit because the history is detailed, the exam is detailed and the medical decision making is of moderate complexity. An established patient visit needs only two out of the three elements of history, examination and medical decision making to determine the level of a visit. The lab 89060 is for crystal identification by light microscopy, with or without polarizing lens analysis, tissue or any body fluid (except urine). The procedure 20600 is for an arthrocentesis, aspiration and/or injection, small joint or bursa (e.g., fingers, toes) without ultrasound guidance.
The ICD-10 M10.27 is for acute drug-induced gout of the right foot and ankle. T50.2X5A is for poisoning by adverse effect of carbonic-anhydrase inhibitors, benzothiadiazides and other diuretics, initial encounter. I10 is for essential (primary) hypertension.
For questions or additional information on coding and documentation guidelines, contact Melesia Tillman, CPC-I, CPC, CRHC, CHA, via email at firstname.lastname@example.org or call 404-633-3777 x820.