Rheumatology March Coding Corner Answer: Pediatric Rheumatology Consult

CPT: 99203

This encounter is coded as 99203, because it included:

History—The history of present illness was extended. The review of systems was complete, and the past medical, family and social were documented. This makes the history comprehensive.
Examination—Expanded detailed.
Medical decision making—The diagnosis was a new problem with no additional workup planned; review and summarization of old records (labs from another physician); acute uncomplicated illness or injury. The medical decision making was of low complexity.

ICD-10: M79.1 Leg muscle pain, noninflammatory.

For questions or additional information on coding and documentation guidelines, contact Melesia Tillman, CPC-I, CPC, CRHC, CHA, at [email protected] or 404-633-3777 x820.

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