AAPC CPC CHAPTER 19
i i i
EmergencyiDepartmentiServicesi-i
✅Frediisifishingiatitheilocaliareailakeiwhileionivacation.iHeigetsilightheadediandidizzyiandigoesitoitheilo
i
calihospitaliEmergencyiDepartment.iHe'sievaluatedibyitheiEDiprovider.iThisiisitheifirstitimeiheihasibeenit
oithisihospital.iWhatisubsectioniisiuseditoireportitheiEDivisit?
32i-i
i ✅Whatimodifieriisiuseditoireportianievaluationiandimanagementiserviceimandatedibyiaicourtiorder?
Establishedipatientiofficeivisiti-i
i✅AipatientiisiseenibyiDr.iBiwhoiisicoveringionicalliservicesiforiDr.iA.iTheipatientiisianiestablishedipatienti
withiDr.iA.ibutisheihasinotibeeniseenibyiDr.iB.ibefore.iWhichiE/Misubcategoryiisiappropriateitoireportithe
iservicesiprovidedibyiDr.iB?
Location,iqualityiandidurationi-i
✅WhichielementsiofiHPIiareimetiinithisistatement?iPatienticomplainsiofiheadacheiandiblurryivisionifori
i
theipasti3idays.
Qualityi-i
i ✅Ifitheipainiisisharp,istabbingioridull,iwhatiisitheicomponentiofitheiHistoryiofiPresentiIllnessi(HPI)?
99475i-i
✅Ai3iyear-
i
oldicriticallyiillichildiisiadmitteditoitheiPICUifromitheiERiwithirespiratoryifailureidueitoianiexacerbationiofi
asthmainotimanageableiinitheiER.iTheiprovideristartsicontinuousibronchodilatoritherapyiandipharmacol
ogicisupportialongiwithicardiovascularimonitoringiandipossibleimechanicaliventilationisupport.iTheipro
videridocumentsiaicomprehensiveihistoryiandiexamiandiordersiareiwritteniafteritreatmentiisiinitiated.i
WhatiisitheiCPTi®icodeiforithisiencounter?
99382i-i
✅Afterimovingiacrossicountry,iMs.iRobbinsitookiheri2iyear-
i
oldidaughteritoiainewipediatricicliniciforianiannualiphysical.iTheiprovidericompletedianiagei/igenderiappr
opriateihistory,iexam,iandiprovidedianticipatoryiguidance.iHeiorderedinoiadditionalitestsioriimmunizati
ons.iWhatiCPT®icodeiisireported?
1i|iP a g e
,99367i-i
✅Aipatientiisiinitheihospitaliafteriaiwedgeiresectioniofitheileftilungidueitoicancer.iHeihasinotibeeniableit
i
oikeepitheilungiinflatediwithoutiaiventilator.iAi45-
minuteiteamiconferenceibetweenitheigeneralisurgeoniwhoiperformeditheisurgery,iaipulmonologist,iani
oncologistiandiaineurologistiisihelditoidiscussitheibestitreatmentiforitheipatient.iTheipatientiand/oripatie
nt'sifamilyiisinotipresent.iWhatiCPT®icodeiisireported?
I20.1i-i
i ✅WhatiICD-10-CMicodeiisireportediforianginaipectorisiwithiaidocumentedispasm?
99393,i99213-25i-i
✅Ai10iyear-
i
oldigirliisischedulediforiheriyearlyiphysicaliwithiheripediatrician.iAtitheitimeiofitheivisit,itheipatienticompl
ainsiofiwateryieyes,iscratchyithroatiandistuffyinoseiforitheipastitwoidays.iTheiprovideriperformsitheiphys
ical.iHeialsoiperformsianiexpandediproblemihistoryiandiexamianditreatsitheipatientiforiaiURI.iWhatiCPT®i
code(s)iis/areireportediforithisivisit?
99242i-i
✅Ai32iyear-
i
oldipatientiseesiDr.iSmithiforiaiconsultiatitheirequestiofihisiPCP,iDr.iLong,iforianiongoingiproblemiwithialle
rgies.iTheipatientihasifailediClaritiniandiAlavertiandifeelsihisisymptomsicontinueitoiworsen.iDr.iSmithiper
formsianiexpandediproblemifocusedihistoryiandiexamiandidiscussesioptionsiwithitheipatientioniallergyi
management.iTheiMDMiisistraightforward.iTheipatientiagreesiheiwouldilikeitoibeitesteditoipossiblyigaini
bettericontroliofihisiallergies.iDr.iSmithisendsiaireportitoiDr.iLongithankingihimiforitheireferraliandiinclud
esitheidateitheipatientiisischedulediforiallergyitesting.iDr.iSmithialsoiincludesihisifindingsifromitheiencou
nter.iWhatiE/Micodeiisireported?
99213,i99354i-i
✅Mr.iFlintstoneiisiseenibyihisioncologistijustitwoidaysiafteriundergoingiextensiveitestingiforiaisuddenio
i
nsetiofipetechiae,inightisweats,iswolleniglandsiandiweakness.iAfteriaibriefireviewiofihistory,iDr.iB.iMarro
wire-
examinesiMr.iFlintstone.iTheiexamiisidocumentediasiexpandediproblemifocusedianditheimedicalidecisio
nimakingiofimoderateicomplexity.iTheioncologistispendsianiadditionali45iminutesidiscussingiMr.iFlintst
one'sinewidiagnosisiofiHodgkin'silymphoma,itreatmentioptionsiandiprognosis.i
Whatiis/areitheiappropriateiprocedureicode(s)iforithisivisit?
Theiacuteitonsillitisiisireportedifirst;itheichronicitonsillitisiisireportedisecond.i-i
2i|iP a g e
,i ✅Aipatientiisidiagnosediasihavingibothiacuteiandichronicitonsillitis.iHowiisithisireportediiniICD-10-CM?
99222i-i
✅Theiprovideriadmittediani18imonth-
i
oldiinfantitoitheihospitalifromihisiofficeitoiruleioutisepsis.iTheiinfantiisicryingiinconsolably.iHeihasiailargei
amountiofigasiinihisibowel,inoihematocheziaiassociatediwithiit.iAicomprehensiveihistory,icomprehensiv
eiexamiandimoderateidecisionimakingiisidocumented.iIficulturesiareinegativeianditheipatientiremainsiaf
ebrileifori48ihours,itheiinfantiwillibeidischargedihome.iWhatiCPT®icodeiisireportediforithisivisit?
99212i-i
i ✅Ai37iyear-oldifemaleiisiseeniinitheicliniciforifollow-upiofiloweriextremityiswelling.
HPI:iPatientiisihereitodayiforifollow-
upiofibilateraliloweriextremityiswelling.iTheiswellingirespondeditoihydrochlorothiazide.
DATAiREVIEW:iIireviewediherilabiandiechocardiogram.iTheipatientidoesihaveimoderateipulmonaryihype
rtension.
Exam:iPatientiisiininoiacuteidistress.
ASSESSMENT:i
1.iBilateraliloweriextremityiswelling.iThisihasiresolvediwithidiuretics;iitimayibeisecondaryitoiproblemi#2.
2.iPulmonaryihypertension:iEtiologyiisinoticleariatithisitime,iwilliworkiupiandipossiblyireferitoiaipulmonol
ogist.
PLAN:iWillievaluateitheipulmonaryihypertension.iPatientiwillibeischedulediforiaisleepistudy.
99235i-i
✅Ai90iyear-
i
oldifemaleiwasiadmittedithisimorningifromiobservationistatusiforichestipainitoir/oiangina.iAicardiologisti
performsiaicomprehensiveihistoryiandicomprehensiveiexam.iHerichestipainihasibeenirelievediwithithein
itroglycerinidripigivenibeforeiadmissioniandisheiwouldilikeitoigoihome.iDoctorihasiwritteniprescriptionsit
oiadditoiheriregimen.iHeihadigiveniheriIsosorbide,iandisheiisitoleratingiitiwell.iHeiwilligoiaheadiandisendih
erihome.iWeiwillifollowiupiwithiheriiniaiweek.iPatientiwasiadmittediandidischargedionitheisameidateiofis
ervice.iWhatiCPT®icodeiisireported?
99291-25,i31500,i36510,i94610i-i
3i|iP a g e
, ✅AniinfantiisibornisixiweeksiprematureiiniruraliArizonaianditheipediatricianiiniattendanceiintubatesith
i
eichildiandiadministersisurfactantiinitheiETitubeiwhileiwaitingiinitheiERiforitheiairiambulance.iDuringithei
45-
minuteiwait,iheicontinuesitoibagitheicriticallyiillipatientioni100ipercentioxygeniwhileimonitoringiVS,iECG,i
pulseioximetryianditemperature.iTheiinfantiisiiniaiwarmingiunitiandianiumbilicaliveinilineiwasiplacediforif
luidsiandiinicaseiofiemergentineediforimedications.iHowiisithisicoded?
99231i-i
✅Theiphysicianiwasicalleditoitheihospitaliflooriforitheimedicalimanagementiofiai56iyear-
i
oldipatientiadmittedioneidayiagoiwithiaspirationipneumoniaiandiCOPD.iNoichestipainiatipresent,ibutistilli
SOBiandisomeiswellingiinihisiloweriextremities.iPatientiwasitachypneiciyesterday;ilungsirevealicourseicr
acklesiinibothibases,irightiworseithanileft.iTheiphysicianiwritesiinstructionsitoicontinueiwithiintravenousi
antibioticitreatmentiandirespiratoryisupportiwithiventilatorimanagement.iHeireviewedichestiX-
rayiandilabs.iPatientiisiimprovingiandiaipulmonaryiconsultationihasibeenirequested.iWhatiCPT®icodeiisir
eported?
99213,iS39.012A,iW01.0XXA,iY92.030i-i
✅Aniestablishedi47iyear-
i
oldipatientipresentsitoitheiprovider'siofficeiafterifallingilastinightiiniheriapartmentiwhenisheislippediiniw
aterionitheikitchenifloor.iSheiisicomplainingiofilowibackipainiandinoitinglingiorinumbness.iProvideridocu
mentsithatisheihasifullirangeimotioniofitheispine,iwithidiscomfort.iHerigaitiisiwithininormalilimits.iStraigh
tilegiraisingiisinegative.iSheirequestedinoimedication.iItiisirecommendeditoiuseiheat,isuchiasiaihotiwateri
bottle.iProvider'siAssessment:iLoweriBackiMuscleiStrain.iWhatiE/MiandiICD-10-
CMicodesiareireportediforithisiservice?
92950,i99291-25,i36556,i31500i-i
✅Ai5iyear-
i
oldiisibroughtitoitheiEmergencyiDepartmentibyiambulance,iHeihadibeenifoundifloatingiiniaipooliforianiun
knowniamountiofitime.iEMSistartediCPRiwhichiwasicontinuedibyitheiEDiproviderialongiwithiendotrache
aliintubationiandiplacementiofiaiCVC.iTheiERiproviderispenti1ihouriwithitheicriticallyiillipatient.iTheiEDipr
oviderimakesiainotationithei1ihouridoesinotiincludeitheitimeiforitheiotheriseparateibillableiservices.iWha
tiCPT®icodesiareireported?
99213i-i
✅Aniestablishedipatientipresentsitoitheiclinicitodayiforiaifollow-
i
upiofihisipneumonia.iHeiwasihospitalizedifori6idaysioniIViantibiotics.iHeiwasiplacedibackioniSingulairiandi
hasibeenidoingiwelliwithihisibreathingisinceithen.iAniexpandediproblemifocusediexamiwasiperformed.iR
ecordsiwereiobtainedifromitheihospitalianditheiproviderirevieweditheilabsiandiX-
rays.iTheipatientiwasitolditoicontinueiantibioticsiforianotheritwoiweeksitoi20idays,ianditheiprescriptioniK
eteckiwasireplacediwithiZithromax.iPatientiisitoireturnitoitheicliniciinitwoiweeksiforirecheckiofihisibreathi
ngiandifollowiupiX-ray.iWhatiCPT®icodeiisireported?
4i|iP a g e
i i i
EmergencyiDepartmentiServicesi-i
✅Frediisifishingiatitheilocaliareailakeiwhileionivacation.iHeigetsilightheadediandidizzyiandigoesitoitheilo
i
calihospitaliEmergencyiDepartment.iHe'sievaluatedibyitheiEDiprovider.iThisiisitheifirstitimeiheihasibeenit
oithisihospital.iWhatisubsectioniisiuseditoireportitheiEDivisit?
32i-i
i ✅Whatimodifieriisiuseditoireportianievaluationiandimanagementiserviceimandatedibyiaicourtiorder?
Establishedipatientiofficeivisiti-i
i✅AipatientiisiseenibyiDr.iBiwhoiisicoveringionicalliservicesiforiDr.iA.iTheipatientiisianiestablishedipatienti
withiDr.iA.ibutisheihasinotibeeniseenibyiDr.iB.ibefore.iWhichiE/Misubcategoryiisiappropriateitoireportithe
iservicesiprovidedibyiDr.iB?
Location,iqualityiandidurationi-i
✅WhichielementsiofiHPIiareimetiinithisistatement?iPatienticomplainsiofiheadacheiandiblurryivisionifori
i
theipasti3idays.
Qualityi-i
i ✅Ifitheipainiisisharp,istabbingioridull,iwhatiisitheicomponentiofitheiHistoryiofiPresentiIllnessi(HPI)?
99475i-i
✅Ai3iyear-
i
oldicriticallyiillichildiisiadmitteditoitheiPICUifromitheiERiwithirespiratoryifailureidueitoianiexacerbationiofi
asthmainotimanageableiinitheiER.iTheiprovideristartsicontinuousibronchodilatoritherapyiandipharmacol
ogicisupportialongiwithicardiovascularimonitoringiandipossibleimechanicaliventilationisupport.iTheipro
videridocumentsiaicomprehensiveihistoryiandiexamiandiordersiareiwritteniafteritreatmentiisiinitiated.i
WhatiisitheiCPTi®icodeiforithisiencounter?
99382i-i
✅Afterimovingiacrossicountry,iMs.iRobbinsitookiheri2iyear-
i
oldidaughteritoiainewipediatricicliniciforianiannualiphysical.iTheiprovidericompletedianiagei/igenderiappr
opriateihistory,iexam,iandiprovidedianticipatoryiguidance.iHeiorderedinoiadditionalitestsioriimmunizati
ons.iWhatiCPT®icodeiisireported?
1i|iP a g e
,99367i-i
✅Aipatientiisiinitheihospitaliafteriaiwedgeiresectioniofitheileftilungidueitoicancer.iHeihasinotibeeniableit
i
oikeepitheilungiinflatediwithoutiaiventilator.iAi45-
minuteiteamiconferenceibetweenitheigeneralisurgeoniwhoiperformeditheisurgery,iaipulmonologist,iani
oncologistiandiaineurologistiisihelditoidiscussitheibestitreatmentiforitheipatient.iTheipatientiand/oripatie
nt'sifamilyiisinotipresent.iWhatiCPT®icodeiisireported?
I20.1i-i
i ✅WhatiICD-10-CMicodeiisireportediforianginaipectorisiwithiaidocumentedispasm?
99393,i99213-25i-i
✅Ai10iyear-
i
oldigirliisischedulediforiheriyearlyiphysicaliwithiheripediatrician.iAtitheitimeiofitheivisit,itheipatienticompl
ainsiofiwateryieyes,iscratchyithroatiandistuffyinoseiforitheipastitwoidays.iTheiprovideriperformsitheiphys
ical.iHeialsoiperformsianiexpandediproblemihistoryiandiexamianditreatsitheipatientiforiaiURI.iWhatiCPT®i
code(s)iis/areireportediforithisivisit?
99242i-i
✅Ai32iyear-
i
oldipatientiseesiDr.iSmithiforiaiconsultiatitheirequestiofihisiPCP,iDr.iLong,iforianiongoingiproblemiwithialle
rgies.iTheipatientihasifailediClaritiniandiAlavertiandifeelsihisisymptomsicontinueitoiworsen.iDr.iSmithiper
formsianiexpandediproblemifocusedihistoryiandiexamiandidiscussesioptionsiwithitheipatientioniallergyi
management.iTheiMDMiisistraightforward.iTheipatientiagreesiheiwouldilikeitoibeitesteditoipossiblyigaini
bettericontroliofihisiallergies.iDr.iSmithisendsiaireportitoiDr.iLongithankingihimiforitheireferraliandiinclud
esitheidateitheipatientiisischedulediforiallergyitesting.iDr.iSmithialsoiincludesihisifindingsifromitheiencou
nter.iWhatiE/Micodeiisireported?
99213,i99354i-i
✅Mr.iFlintstoneiisiseenibyihisioncologistijustitwoidaysiafteriundergoingiextensiveitestingiforiaisuddenio
i
nsetiofipetechiae,inightisweats,iswolleniglandsiandiweakness.iAfteriaibriefireviewiofihistory,iDr.iB.iMarro
wire-
examinesiMr.iFlintstone.iTheiexamiisidocumentediasiexpandediproblemifocusedianditheimedicalidecisio
nimakingiofimoderateicomplexity.iTheioncologistispendsianiadditionali45iminutesidiscussingiMr.iFlintst
one'sinewidiagnosisiofiHodgkin'silymphoma,itreatmentioptionsiandiprognosis.i
Whatiis/areitheiappropriateiprocedureicode(s)iforithisivisit?
Theiacuteitonsillitisiisireportedifirst;itheichronicitonsillitisiisireportedisecond.i-i
2i|iP a g e
,i ✅Aipatientiisidiagnosediasihavingibothiacuteiandichronicitonsillitis.iHowiisithisireportediiniICD-10-CM?
99222i-i
✅Theiprovideriadmittediani18imonth-
i
oldiinfantitoitheihospitalifromihisiofficeitoiruleioutisepsis.iTheiinfantiisicryingiinconsolably.iHeihasiailargei
amountiofigasiinihisibowel,inoihematocheziaiassociatediwithiit.iAicomprehensiveihistory,icomprehensiv
eiexamiandimoderateidecisionimakingiisidocumented.iIficulturesiareinegativeianditheipatientiremainsiaf
ebrileifori48ihours,itheiinfantiwillibeidischargedihome.iWhatiCPT®icodeiisireportediforithisivisit?
99212i-i
i ✅Ai37iyear-oldifemaleiisiseeniinitheicliniciforifollow-upiofiloweriextremityiswelling.
HPI:iPatientiisihereitodayiforifollow-
upiofibilateraliloweriextremityiswelling.iTheiswellingirespondeditoihydrochlorothiazide.
DATAiREVIEW:iIireviewediherilabiandiechocardiogram.iTheipatientidoesihaveimoderateipulmonaryihype
rtension.
Exam:iPatientiisiininoiacuteidistress.
ASSESSMENT:i
1.iBilateraliloweriextremityiswelling.iThisihasiresolvediwithidiuretics;iitimayibeisecondaryitoiproblemi#2.
2.iPulmonaryihypertension:iEtiologyiisinoticleariatithisitime,iwilliworkiupiandipossiblyireferitoiaipulmonol
ogist.
PLAN:iWillievaluateitheipulmonaryihypertension.iPatientiwillibeischedulediforiaisleepistudy.
99235i-i
✅Ai90iyear-
i
oldifemaleiwasiadmittedithisimorningifromiobservationistatusiforichestipainitoir/oiangina.iAicardiologisti
performsiaicomprehensiveihistoryiandicomprehensiveiexam.iHerichestipainihasibeenirelievediwithithein
itroglycerinidripigivenibeforeiadmissioniandisheiwouldilikeitoigoihome.iDoctorihasiwritteniprescriptionsit
oiadditoiheriregimen.iHeihadigiveniheriIsosorbide,iandisheiisitoleratingiitiwell.iHeiwilligoiaheadiandisendih
erihome.iWeiwillifollowiupiwithiheriiniaiweek.iPatientiwasiadmittediandidischargedionitheisameidateiofis
ervice.iWhatiCPT®icodeiisireported?
99291-25,i31500,i36510,i94610i-i
3i|iP a g e
, ✅AniinfantiisibornisixiweeksiprematureiiniruraliArizonaianditheipediatricianiiniattendanceiintubatesith
i
eichildiandiadministersisurfactantiinitheiETitubeiwhileiwaitingiinitheiERiforitheiairiambulance.iDuringithei
45-
minuteiwait,iheicontinuesitoibagitheicriticallyiillipatientioni100ipercentioxygeniwhileimonitoringiVS,iECG,i
pulseioximetryianditemperature.iTheiinfantiisiiniaiwarmingiunitiandianiumbilicaliveinilineiwasiplacediforif
luidsiandiinicaseiofiemergentineediforimedications.iHowiisithisicoded?
99231i-i
✅Theiphysicianiwasicalleditoitheihospitaliflooriforitheimedicalimanagementiofiai56iyear-
i
oldipatientiadmittedioneidayiagoiwithiaspirationipneumoniaiandiCOPD.iNoichestipainiatipresent,ibutistilli
SOBiandisomeiswellingiinihisiloweriextremities.iPatientiwasitachypneiciyesterday;ilungsirevealicourseicr
acklesiinibothibases,irightiworseithanileft.iTheiphysicianiwritesiinstructionsitoicontinueiwithiintravenousi
antibioticitreatmentiandirespiratoryisupportiwithiventilatorimanagement.iHeireviewedichestiX-
rayiandilabs.iPatientiisiimprovingiandiaipulmonaryiconsultationihasibeenirequested.iWhatiCPT®icodeiisir
eported?
99213,iS39.012A,iW01.0XXA,iY92.030i-i
✅Aniestablishedi47iyear-
i
oldipatientipresentsitoitheiprovider'siofficeiafterifallingilastinightiiniheriapartmentiwhenisheislippediiniw
aterionitheikitchenifloor.iSheiisicomplainingiofilowibackipainiandinoitinglingiorinumbness.iProvideridocu
mentsithatisheihasifullirangeimotioniofitheispine,iwithidiscomfort.iHerigaitiisiwithininormalilimits.iStraigh
tilegiraisingiisinegative.iSheirequestedinoimedication.iItiisirecommendeditoiuseiheat,isuchiasiaihotiwateri
bottle.iProvider'siAssessment:iLoweriBackiMuscleiStrain.iWhatiE/MiandiICD-10-
CMicodesiareireportediforithisiservice?
92950,i99291-25,i36556,i31500i-i
✅Ai5iyear-
i
oldiisibroughtitoitheiEmergencyiDepartmentibyiambulance,iHeihadibeenifoundifloatingiiniaipooliforianiun
knowniamountiofitime.iEMSistartediCPRiwhichiwasicontinuedibyitheiEDiproviderialongiwithiendotrache
aliintubationiandiplacementiofiaiCVC.iTheiERiproviderispenti1ihouriwithitheicriticallyiillipatient.iTheiEDipr
oviderimakesiainotationithei1ihouridoesinotiincludeitheitimeiforitheiotheriseparateibillableiservices.iWha
tiCPT®icodesiareireported?
99213i-i
✅Aniestablishedipatientipresentsitoitheiclinicitodayiforiaifollow-
i
upiofihisipneumonia.iHeiwasihospitalizedifori6idaysioniIViantibiotics.iHeiwasiplacedibackioniSingulairiandi
hasibeenidoingiwelliwithihisibreathingisinceithen.iAniexpandediproblemifocusediexamiwasiperformed.iR
ecordsiwereiobtainedifromitheihospitalianditheiproviderirevieweditheilabsiandiX-
rays.iTheipatientiwasitolditoicontinueiantibioticsiforianotheritwoiweeksitoi20idays,ianditheiprescriptioniK
eteckiwasireplacediwithiZithromax.iPatientiisitoireturnitoitheicliniciinitwoiweeksiforirecheckiofihisibreathi
ngiandifollowiupiX-ray.iWhatiCPT®icodeiisireported?
4i|iP a g e
