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Code This!

Scenario Week of February 26, 2014:
View Current Scenario

Assign the correct codes for the following scenario using ICD-9-CM, ICD-10-CM codes, and CPT procedure codes:

Chief Compliant
This known patient presented for her annual preventive exam.

The patient had no acute complaints and stated that she was in good health. She had no vaginal bleeding or problems and has a history of hysterectomy. She was sexually active, but with decreasing frequency. Her only physical complaint was occasional catch in her right hip. No associated swelling, inflammation, or pain.

Inderal LA 80 mg every other day

Sulfa drugs

Past History
History of rosacea, tremors treated with Inderal, hysterectomy 10 years ago

Social History
Married and caretaker of her husband who has difficulty with his nondominant arm and shoulder. She walks nearly every day. Up to four cups of coffee a day, but no soda or chocolate.

Family History
Father died of congestive heart failure at age 86. Mother had a stroke at age 92 and is in a nursing facility. One brother with kidney failure; the other brother donated a kidney and is subsequently addicted to alcohol and drugs. She has two daughters and one son in good health.

Review of Systems
She fell and hit her head about six months ago and had intermittent headaches but no cerebral bleeds by history. No blurred or double vision, no tinnitus, infection, or hearing problems. She reported having an occasional sore throat. No shortness of breath, cough, chest pain, palpitations, hypertension, or edema noted. She denied nausea, vomiting, diarrhea, or constipation. No stress incontinence, frequency, or urgency but she reported waking several times in the night to urinate. No muscle or bone pain or weakness other than noted above. No postmenopausal bleeding. Patient denied any breast tenderness, mass, lumps, or discharge. She denied depression or anxiety. All other systems were negative.

5 feet 5 inches tall, 165 pounds. Blood pressure 116/80, pulse 62 and respirations 18. This 61-year-old female was well-nourished and well-developed with good mentation and appropriate answers.
Head was normocephalic.
Extraocular movements intact, pupils equal, round, and reactive to light and accommodation. Patient wears glasses for both near and far vision.
Tympanic membranes were intact.
No oral lesions, mucosa moist, tonsils present, noninflamed.
No thyromegaly or lymphadenopathy.
Lungs were clear to auscultation and percussion.
Heart was regular rate and rhythm without murmur.
Breasts were normal appearing for age, nontender, no masses or lumps, nipple discharge, or retraction.
No axillary nodes detected.
Abdomen was soft, nontender, no masses. Bowel sounds were present.
Pulses present in all four extremities with reflexes intact. No edema detected. Gait was normal. No spinal tenderness of deformity.
Vaginal mucosa was atrophic, cervix and uterus absent. Pap smear was taken and sent for pathology evaluation. No adnexal masses. Rectal tone good, no masses and stool guaiac negative.

Middle-aged woman in good health, status post hysterectomy not on hormone replacement.

She has not had her routine health screening for at least five years. Screening will be ordered. Encouraged patient to keep yearly evaluation appointments.

Tests ordered:
Screening mammogram
DEXA screening
Metabolic panel
Lipid profile
Will see her in one year unless she has health issues.

Select the correct CPT, ICD-9-CM, and ICD-10-CM codes for this office visit.

Answers and Rationale

99396 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 40–64 years
S0612 Annual gynecological examination, established patient

LThe patient is stated to be a known patient of the examiner and presented for her annual preventive exam. In the exam portion, the provider indicates that the patient is 61 years old, making code 99396 the right code to assign for the preventive exam. This is confirmed by review of the documentation. No health problems were treated, no medications were changed, and the diagnostic tests ordered were screening services expected for someone of her age.

The gynecological exam for a patient may also be reported with code S0612. Some payers may consider this to be inherent in the CPT code 99396, and others may want this code to specify that the gynecological exam was also performed.

V70.0 Routine general medical examination at health care facility
V72.31 Routine gynecological examination
V76.47 Special screening for malignant neoplasms, vagina
V88.01 Acquired absence of both cervix and uterus
781.0 Tremors
V14.2 Allergy to sulfa drugs

The routine general medical exam without treatment of a confirmed diagnosis is reported with code V70.0.

The routine gynecological examination without treatment of a confirmed diagnosis is reported with code V72.31, and the vaginal exam and obtaining of the Pap smear are reported with code V76.47.

It is noted that the patient had a hysterectomy, and the exam notes absence of cervix and uterus. The acquire absence of these organs is reported with code V88.01.

The patient is on Inderal for tremors, 781.0, and has a history of allergy to sulfa drugs, V14.2. These are relevant to the encounter as one condition is being treated currently, and the allergy would be a consideration for medications and planning.

Z00.00 Encounter for general adult medical examination without abnormal findings
Z01.419 Encounter for gynecological examination (general) (routine) without abnormal findings
Z12.72 Encounter for screening for malignant neoplasm of vagina
Z90.710 Acquired absence of both cervix and uterus
R25.1 Tremor, unspecified
Z88.2 Allergy status to sulfonamides status

The index main term “Examination (general)” refers the user to Z00.00, which is confirmed in the tabular list. It is important to note that this code specifically indicates that no abnormal findings were detected. If there were an abnormality, code Z00.01 Encounter for general adult medical examination with abnormal findings, would be reported in lieu of Z00.00. Note that if Z00.01 is listed, additional codes identifying the abnormal findings are also reported, according to the guideline below this code and official guideline 1.C.21.c.13. This code is used for the general exam portion of the patient encounter.

The index main term “Examination,” subterm “gynecological” refers the user to Z01.419, which is verified in the tabular list. Instructions for category Z01.41- indicate that additional codes should be reported to identify a vaginal Pap smear, if applicable, and the acquired absence of the uterus. This code is specific to the gynecological portion of the general exam.

The index main term “Screening,” subterms “neoplasm, genitourinary organs, vagina” refer the user to Z12.72, which is confirmed in the tabular as the correct code. Text below Z12.72 indicates that this code is used “status-post hysterectomy” for screening. This is more appropriate than code Z12.4, which describes the screening of the cervix and includes an excludes1 note for gynecological exam (Z01.419).

The index main term “History,” subterms “personal, hysterectomy” refer the user to Z90.710. This is confirmed in the tabular list. Without further information, this is the correct code. A note under Z90.710 indicates that this code is used for “acquired absence of uterus NOS.”

The alphabetic main index term “Tremor(s)” indicate R25.1, which is the general code for unspecified type as seen in the tabular list.

The alphabetic main index term “History, personal, allergy (to), sulfonamides” indicates Z88.2, which is confirmed by the tabular list. It is relevant to the encounter for medication and planning.

CPT is a registered trademark of the American Medical Association.
CPT © 2013 American Medical Association. All rights reserved.

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