Correct Answer:
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.
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.