CPT codes: 99213
ICD-9: 715.15, 278.01
ICD-10: M16.12, E66.01, Z68.41
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This encounter is coded as 99213 as follows:
- History—The history of present illness was extended. The review of systems was comprehensive, and no past family social history was documented. This makes the history level expanded problem focused.
- Examination—There were eight systems examined. This makes the exam level comprehensive.
- Medical decision making—The diagnosis was an established problem worsening, an X-ray was ordered, and there was prescription drug management. This makes the medical decision making level low complexity.
The M16.12 code is for unilateral primary osteoarthritis of the left hip. The E66.01 code is for morbid obesity due to excess calorie intake. Note: When coding for morbid obesity in ICD-10 (E66.01), the coding rule indicates that the body mass index (BMI) must be included on the claim form. The BMI is categorized by age and then by level of the BMI, which is coded as Z68.41.