I may be over thinking this but I want to be sure I have it correct before I move on. I noticed another person had previously asked this question but I didn't see any answers or suggestions so I'll go ahead and ask it again. My scenario is as follows: Chester has an appointment for a check-up on his asthma. He is wheezy and having labored breathing. His established physician performs a problem focused exam and history. No further treatment is recommended for it. Chester is to return in three months for a checkup on his atopic asthma. So I know that the CPT code is 99212 and I'm pretty certain that the ICD-9-CM code is V70 because the physician isn't diagnosing this patient with a new ailment he's just doing a checkup on an already existing problem...am I right?
I have no idea what those codes are, but your logic seems sound. It's not a new ailment.
Kathy, a 33 year old established patient sees Dr. Owens in her office for what she thinks is a sinus infection. Her history and exam are both expanded problem focused with the decision of making low complexity. Her diagnosis is acute sinusitis. What is the CPT Code and ICD-9-Cm code?
you must be taking the exact test i am right now :) That is what i came up with.
Icd-9-cm code is 461.
Cot code is 461.1
It seems like you have some understanding of the coding process, but there are a few things that need clarification.
In the scenario you described, Chester is visiting his established physician for a check-up on his asthma. The physician performs a problem-focused exam and history. Based on this information, you correctly identified the CPT code as 99212, which represents an established patient visit that requires a straightforward level of medical decision-making.
However, the ICD-9-CM code you mentioned, V70, is not appropriate in this case. V70 is a general code that denotes a routine, administrative, or general medical examination without any indication of a specific condition. In Chester's case, he has an existing condition, namely his atopic asthma. Therefore, you need to use an ICD-9-CM code that accurately describes his condition.
For asthma, the ICD-9-CM code would depend on the specific type or manifestation of asthma. It could be something like 493.90 for uncomplicated asthma, 493.92 for cough-variant asthma, or a more specific code if additional details are available.
To ensure accurate coding, it's always best to refer to the most recent version of the coding manual and consult any relevant coding guidelines. Additionally, the final coding decision should be made by a certified medical coder or healthcare professional with coding expertise, as codes may vary based on payer requirements and specific clinical documentation.