A 13-year-old black male, described by his mother as a very active and energetic child, is referred to a pediatric rheumatologist. His chief complaint is muscle pain in both legs, which he has experienced for the past three weeks. His mother is a patient of an adult rheumatologist at this clinic and is quite concerned….
Rheumatology Coding Corner Answer: Gout Visit for Established Patient
CPT: 99213, 89060 ICD-10: M10.072 Coding Rationale This is an established outpatient visit. The encounter is coded as 99213 because it included: History—Expanded problem-focused history. The history of present illness was brief, the review of systems was extended and the past medical and social history was documented. Examination—Detailed. There were seven organ systems examined. This…
Rheumatology Coding Corner Question: Gout Visit for Established Patient
A 55-year-old female patient returns to the office with complaints of gout pain. She is complaining of swelling and a burning pain in her left toe. She has been taking an over-the-counter NSAID to treat the pain, but this has done little to alleviate it. This is her second flare this year. The patient denies…
Rheumatology Coding Corner Answer: Level 4 New Patient Visit
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 Corner Question: Level 4 New Patient Visit
A 32-year-old female patient comes in for an initial visit. She is self-referred and complains of pain, numbness and color changes in her fingers when exposed to cold. The patient reports that her right distal index finger, left distal index finger and fourth right finger turn white and blue with pain and numbness when exposed…
Patient-Recorded Office Visits Concern Physicians
Over the years, cell phones have evolved from purse-size behemoths to the size of a wristwatch. In addition, they have moved from basically a portable telephone to the smartphones of today. Both the changes in size and the added functions have resulted in new concerns for physicians. “We had a family meeting about two years…
Healthcare Office Design Can Make a Positive Difference for Rheumatology Patients
When designing healthcare spaces to foster wellness, you should first understand the particular patient illness being served and then determine that population’s fundamental needs. “Providers who serve patients with rheumatoid conditions should identify the range of clinical presentations specific to their patient population,” advises Sharon E. Woodworth, AIA, ACHA, EDAC, Healthcare Practice Leader, Perkins+Will Architects,…
Rheumatology Coding Corner Question: Sacroiliac Injection with Office Visit
Coding for SI Injections with Office Visit A female patient previously diagnosed with sacroiliitis and ankylosing spondylitis returns to the office for a follow-up visit. The patient reports her lower back has been stiff and swollen for the past couple of weeks. She is currently on celecoxib and ranitidine, and mentions that she had some…
Rheumatology Coding Corner Answer: Sacroiliac Injection with Office Visit
CPT codes: 99214-25, 27096, J3301 x1 ICD-9: 720.2, 720.0, 787.02 ICD-10: M46.1*, M45.9*, R11.0 This encounter is coded as 99214 because it includes: Detailed history; Comprehensive examination—eight systems counted; and Medical decision making—moderate complexity (established problem, new problem with no additional workup; new prescription drug ordered). Keep in mind, the CT guidance is an inclusive…