A 67-year-old female patient with Medicare returns to the office for a follow-up of her age-related osteoporosis. She states she has an achy pain in her left hip that lasts for 30–40 minutes in the morning. Currently, she has taken ibandronate sodium and alendronate sodium for the past year, and her pain level is a 7 out of 10. The patient indicates that she has general fatigue and pain in the left hip. All other systems are negative. She does not smoke or drink. The rheumatologist performs an expanded problem-focused examination.
Her last dual-energy X-ray absorptiometry (DEXA) was one year ago. After a treatment course is discussed with the patient, the physician concludes that a DEXA scan is needed, because the patient is on a current regimen of glucocorticoids. The physician sends her to the imaging room for a dual-energy X-ray of the axial skeleton and a vertebral fracture assessment, and schedules her for a follow-up visit in one month.
How is this encounter coded?