ICD-10: M05.79, R05, R06.2
History—Detailed: The history of present illness (HPI) was extended; the review of systems (ROS) was extended; and the past medical, family and social history (PFSH) were documented. All three components of the HPI, ROS and PFSH are needed to achieve the detailed history level.
Examination—Detailed: Six systems were examined.
Medical decision making—Moderate complexity: The number of problems was extended, established, worsening and one new problem with additional workup planned. The amount of data ordered was an X-ray of the chest and a TB test. The level of risk was prescription drug management, which is moderate. The MDM for this visit is moderate complexity as only two of the three MDM elements are needed to determine the level.
71045: Radiologic examination, chest, single view—this replaces 71010 as of January 2018.
86580: TB skin test. The 86580 is required before starting a patient on infliximab.
For questions or additional information on coding and documentation guidelines, contact Melesia Tillman, CPC-I, CPC, CRHC, CHA, via email at [email protected] or call 404-633-3777 x820.
