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You are here: Home / Articles / Rheumatology Coding Corner Answer: Level 4 New Patient Visit

Rheumatology Coding Corner Answer: Level 4 New Patient Visit

September 7, 2016 • By From the College

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  • Coding Corner Answer

Correct Answer:

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CPT: 99204
ICD-10: I73.00

Coding Rationale

This is a new patient, outpatient visit for a self-referred patient. There is no formal consultation request from another physician; therefore, the encounter does not meet criteria for a consultation.

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This encounter is coded as 99204 because it included:

  • Comprehensive history—Extended history of the present illness, complete review of systems and complete past family social history were documented.
  • Comprehensive examination—12 systems.
  • Moderate complexity decision making—New problem with additional workup planned; extensive laboratory studies ordered; prescription medication therapy initiated.

The ICD-10 code I173.00 is for Raynaud’s phenomenon without gangrene.

Filed Under: Billing/Coding, From the College Tagged With: Billing, Coding, office visit, patient care, Practice Management, rheumatologist, rheumatologyIssue: September 2016

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