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An official publication of the ACR and the ARP serving rheumatologists and rheumatology professionals

Search results for: ICD-10

Rheumatology Coding Corner Answer: Level 4 New Patient Visit

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Take the challenge. Correct Answer: CPT: 99204 ICD-10: I73.00 Coding Rationale This is a new patient, outpatient visit for a self-referred patient. There is no formal consultation request from another physician; therefore, the encounter does not meet criteria for a consultation. This encounter is coded as 99204 because it included: Comprehensive history—Extended history of the…

Rheumatology Coding Answer: Level 3 Established Patient Evaluation and Management Office Visit

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Take the challenge. CPT: 99213 Diagnosis Codes: M05.79, M17.12, Z79.1, Z79.899 Rationale to code this encounter as 99213: History—The history of present illness was extended. The review of systems was comprehensive, and two of the three past, family and social history were documented. This makes the history level comprehensive. Eight systems were examined. This makes…

How Sick Is Your Patient? Document the Details!

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Clear. Complete. Concise. These three Cs describe ideal patient record keeping, which is why they are among the key reasons to implement a clinical documentation information (CDI) program into your rheumatology practice. Not only will CDI help you accurately document the full picture of each patient’s clinical status, but it also promotes high-quality care and…

Rheumatology Coding Corner Answer: Physical Examination with Infliximab Infusion

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Take the challenge. CPT: 99214-25, 96413, 96415 x 1, J1745 x 35 ICD-10: M07.68, K51.80 Billing Overview It is appropriate to bill for an E/M visit for this day of service along with the infusion procedure. Modifier 25 should be appended to the E/M, indicating that the patient received a significant, separately identifiable E/M service…

Rheumatology Coding Corner Answer: Office Visit with DEXA Scan

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Take the challenge. CPT: 99213-25, 77085 ICD-10: Diagnosis M81.0, Z79.52 The encounter is coded as 9913 as follows: History—The history of the present illness was extended. The review of systems was complete, and the past medical history was documented. This makes the history detailed. Examination—The examination was expanded problem focused. Medical decision making—The diagnosis was…

Rheumatology Coding Corner Answer: Documentation Improvement

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Take the challenge. B—No. Although the documentation states the patient arrived at the clinic at 8:15 a.m. and left the clinic at 10:55 a.m., it does not document the actual start and stop times of the infusion. According to CPT, when reporting codes for which infusion time is a factor, use the actual time over…

Rheumatology Coding Corner Question: Coding & Billing Basics

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When reporting E/M service levels, if time spent counseling and/or coordinating care dominates the session, which of the following is true? Total time must be documented Greater than 50% of the time must be for face-to-face counseling and/or coordinating care The extent of the counseling and/or coordinating care must be documented All of the above…

Rheumatology Coding Corner Answer: Coding & Billing Basics

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Take the challenge. 1. D: All of the above Rationale: Per CPT, if time spent counseling and/or coordinating care dominates the session, then total time must be documented; greater than 50% of the time must be for face-to-face counseling and/or coordinating care, and must be documented as such. Additionally, the extent of the counseling and/or…

Opinion: Politics Should Not Trump Science in Medicine

John A. Goldman, MD  |  

I tell my patients there are three types of science: 1) investigative science, which sometimes gets it right; 2) science in the courtroom, which is junk science; and 3) science in Washington, D.C., which is political science. Our decisions are based on art and science; our patients’ medications are brought to market based on science….

The ACR’s Grassroots Advocacy Efforts Rely on Rheumatology Patients

Joan M. Von Feldt, MD, MSEd, FACR, FACP  |  

Over the past several years, the ACR has ramped up its efforts in advocacy. Under the leadership of the Government Affairs Committee, many ACR staff, members and their patients, considerable progress has been made moving priority issues forward in 2015. A few highlights from 2015 include: The Patients’ Access to Treatment Act (PATA) was introduced…