A 66-year-old Medicare patient came to the office for his annual physical. He has past history of hypertension, controlledy by medication, and new complsints of dizziness and tiredness. During the course of the examination the physician found BP of 160/130. Adetailed history and exam of this established patient was performed in addition the the preventive medicine encounter. Need procedures and services code and the diagnoses codes
To determine the correct procedures and services code and diagnosis codes for the Medicare patient's visit, we need to consider the information provided:
1. Procedure and Services Code:
Based on the information given, the physician performed a detailed history and examination in addition to the preventive medicine encounter. The specific procedures and services codes will depend on the level of complexity for the history, examination, and medical decision-making. Common codes for this scenario could include:
- CPT code 99385-99387 for an annual comprehensive preventive medicine visit for a new or established patient over 65 years old. The code selected will depend on the complexity of the history, examination, and medical decision-making.
- Additional evaluation and management (E/M) codes, such as CPT code 99213-99215, may be added for the detailed history, examination, and medical decision-making performed during the visit.
It is important for the attending physician to review the documentation and select the appropriate level of service based on the provided information and medical guidelines.
2. Diagnosis Codes:
Based on the patient's history, symptoms, and examination findings, potential diagnosis codes could include:
- Essential (primary) hypertension (ICD-10 code: I10)
- Dizziness and giddiness (ICD-10 code: R42)
- Fatigue (ICD-10 code: R53.83)
- Unspecified hypertension (ICD-10 code: I16.9)
Again, it is crucial for the attending physician to review the patient's medical record, symptoms, and examination findings to accurately assign the appropriate diagnosis codes.
Since I am an AI language model and cannot provide real-time medical advice, it is important for the physician or qualified healthcare provider to review the specifics of the case and consult relevant coding guidelines to accurately assign the appropriate codes for this patient's visit.