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
The patient underwent a percutaneous needle core biopsy not using imaging. What is the correct code and modifier?
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Based on the provided information, here are the procedure and diagnosis codes for this scenario:
Procedure Code:
CPT Code for comprehensive preventive medicine examination (Annual Physical): 99397
Diagnosis Codes:
1. Hypertension (pre-existing condition, controlled by medication): I10
2. Dizziness: R42
3. Tiredness: R53.83
It's important to note that these codes are based on the limited information provided and may not cover all the possible diagnoses and procedures that could be relevant to this patient. It's always recommended to consult with a certified medical coder or healthcare professional for accurate coding specific to each patient's medical record.
To determine the appropriate procedure and diagnosis codes for this scenario, you need to follow the coding guidelines provided by the current edition of the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) and the Current Procedural Terminology (CPT) codebook. Here's how you can go about it:
1. Diagnoses Codes:
The physician performed a detailed history and examination on an established patient during the annual physical, and found a high blood pressure reading. Based on the information provided, the following diagnosis codes are potential options:
a. Hypertension: ICD-10-CM code - I10
b. Dizziness: ICD-10-CM code - R42
c. Tiredness: ICD-10-CM code - R53.83
2. Procedure and Services Codes:
Since a detailed history and examination were performed in addition to the preventive medicine encounter, the appropriate CPT code would be for an Initial Preventive Physical Examination (IPPE), also known as an "Welcome to Medicare" visit. Based on the age of the patient, this falls under the G0402 code.
In summary, the possible codes for this scenario may include:
- Diagnosis Codes: I10, R42, R53.83
- Procedure and Services Code: G0402
It's important to note that the final codes chosen will depend on the complete documentation and any additional findings during the encounter. To ensure accurate coding, it's recommended to consult the current coding guidelines and seek assistance from a certified medical coder or coding professional.