Rheumatology Coding Question: Deconstructing Evaluation and Management Codes

1. A 50-year-old male patient returns to the office for a follow-up visit for a diagnosis of generalized primary osteoarthritis of multiple sites. The patient tells the medical assistant that he is experiencing sharp throbbing pain in his left hip and right and left knees. He states the pain level is 6 out of 10 and lasts for about an hour in the morning. Would this history of present illness (HPI) be acceptable?
   1. Yes
   2. No
2. An established patient is on a high-risk medication. Would the medical decision making be high risk for this patient?
   1. Yes
   2. No
3. The medical decision making states the patient is assessed with having rheumatoid arthritis that is RF negative of multiple sites. The treatment plan is to continue with 10 mg of methotrexate, and the patient is scheduled for their first infliximab infusion in two weeks. The patient is assessed with having generalized osteoarthritis of the left knee. The treatment plan is to have the patient schedule an MRI of the left knee. It is also documented that the patient has comorbidities of diabetes and hypertension. Which ICD-10 codes should be coded?
   1. M06.09, M17.12
   2. M06.09, M17.12, E11.9
   3. M06.09, M17.12, E11.9, I10
   4. None of the above
4. A new rheumatologist has joined the practice and brings some of her established patients from her former practice. If one of the other rheumatologists sees one of the established patients for the first visit, how should the visit be billed?
   1. New patient
   2. Established patient
5. A midlevel provider is seeing an established patient, but during the visit the patient complains of a new problem. The supervising physician is busy with another patient and cannot assess the new problem, so it is decided that the midlevel provider can treat the problem and not bill the service as incident-to. The patient returns to the practice four weeks later with the same problems from the last visit. Can this now be coded as an incident-to visit without the supervising physician’s input?
   1. Yes
   2. No

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