Rheumatology Coding Corner Answer: Level 4 New Patient Visit

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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.