CPT code: 99214
Diagnosis: ICD-9 274.02
History—The history of present illness was extended. The review of systems was extended (six systems were reviewed), and two of the three elements for past family social history were documented. This makes the history level detailed.
Examination—Three systems were examined. This makes the exam expanded problem focused.
Medical decision making—The number of the diagnosis was for an established problem that was stable, which is minimal. The amount of data was limited. The level of risk was moderate for prescription drug management. This makes the medical decision making low complexity.
Please note: The documentation of the history, exam and medical decision making would normally make this a level three visit (99213). Because the amount of time and what was discussed were documented and more than 50% of the visit was spent with the patient face to face, time is the key factor in determining the level of this visit. CPT states that an established patient level four visit is typically 25 minutes long; this visit was 30 minutes long and, therefore, qualifies to be coded as level four (99214).
**The code M1A.0720 is idiopathic chronic gout of the left ankle and foot without tophi. Note, according to ICD-10 coding guidelines, acute gout and chronic gout cannot be coded together on the same encounter. This guideline falls under the Excludes 1 rule, which indicates that these two diagnoses are mutually excluded and the two conditions cannot be reported together.
Take this opportunity to download and review the top 40 Rheumatology ICD-10 Crosswalk.
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