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Scenario Week of August 01, 2014:
View Current Scenario

Assign the correct 2014 CPT and ICD-9-CM diagnosis codes for the following outpatient coding scenario.

Office Evaluation and Management

CC: Followup of CHF, diabetes, hyperlipidemia and arthritis

HISTORY OF PRESENT ILLNESS: The patient’s congestive heart failure has been stable on the current regimen. Diabetes type II, A1c improved with increased doses of NPH insulin. Hyperlipidemia, well controlled on statin therapy, chronic renal insufficiency is stable, and arthritis is stable. The patient has been doing quite well since he was last seen. He comes in today with his daughter. He has had no symptoms of CAD or CHF. He had follow-up with Dr. X and she also thought he was doing quite well. He has had no symptoms of hyperglycemia or hypoglycemia. He has had no falls. His right knee does pain him at times and he is using occasional doses of Tylenol for that. He wonders whether he could use a knee brace to help him with that issue as well. His spirits are good. He has had no incontinence.


  1. Bumex - 2 mg daily
  2. Aspirin - 81 mg daily
  3. Lisinopril - 40 mg daily
  4. NPH insulin - 65 units in the morning and 25 units in the evening
  5. Zocor - 80 mg daily
  6. Toprol-XL - 200 mg daily
  7. Protonix - 40 mg daily
  8. Chondroitin/glucosamine - no longer using

EXAMINATION: Weight 240, blood pressure by nurse 160/80, by me 140/78, pulse 91 and regular, and O2 saturation 94%. He is afebrile. Respiratory: CTA. CV: RRR. Aortic murmur unchanged. MS: Bilateral OA changes of the knee.

Creatinine 1.7, which was down from 2.3. A1c 7.6 down from 8.5. Total cholesterol 192, LDL 77, and triglycerides 164.


  1. Congestive heart failure, stable on current regimen. Continue.
  2. Diabetes type II, A1c improved with increased doses of NPH insulin. Doing self-blood glucose monitoring with values in the morning between 100 and 130, continue current regimen. Recheck A1c on return.
  3. Hyperlipidemia, well controlled. TSH was normal. Check fasting lipid panel today.
  4. Arthritis, stable. I told the patient he could use Extra Strength Tylenol up to 4 grams a day, but I suggest that he start with a regular dose of 1 to 2 to 3 grams per day. He states he will inch that up slowly. With regard to a knee brace, he stated he used one in the past and that did not help very much. I worry a little bit about the tourniquet type effect of a brace that could increase his edema or put him at risk for venous thromboembolic disease. For now he will continue with his cane and walker.

PLANS: Followup in 3 months, by phone sooner as needed.

Please assign the correct ICD-9-CM and CPT codes for the procedure above.


CPT Code
99214 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 25 minutes are spent face-to-face with the patient and/or family

In the index of CPT 2014, Professional Edition, under the main term Evaluation and management, Office and Other Outpatient, the coder is directed to codes 99201–99215. The first determination the coder must verify is whether this is a new or established patient. This is a follow-up visit which means the patient is established with the practice. Codes 99211–99215 are appropriate for established office and other outpatient visits.

For this type of encounter we see that 2 of the 3 key components must satisfy the documentation requirements to assign the appropriate level of service. Using the 1995 guidelines, in this example, history and MDM meet or exceed the requirements for a level 4 established visit. The examination in this case qualifies as Expanded Problem Focused (four organ systems examined) which meets the requirements for a level 2 or 3 established office visit. This does not affect the code selection in this case as only 2 of 3 components are needed for a given level.

Using 1995 Documentation Guidelines
This encounter qualifies as a detailed history because the status of three or more chronic illnesses (CHF, diabetes, hyperlipidemia, arthritis) is given. (We are using 1995 guidelines for this encounter but remember, last year CMS stated that the status of three or more chronic conditions (1997 Guideline for HPI), may be used in combination with the 1995 guidelines beginning in September 2013). An extended ROS was documented which included cardiovascular, genitourinary, musculoskeletal, psychiatric, and endocrine. Plus a pertinent PFSH was documented (medications were listed).

This encounter qualifies as moderate complexity MDM. Although no dramatic changes were made to the course of treatment and the patient’s chronic conditions were stable or improving, this does not diminish the complexity of dealing with multiple interlocking diagnoses. In this case there are four conditions addressed which gives four problem points for diagnoses and management options and is considered high complexity. Only one data point for labs ordered/reviewed is considered Straightforward data review. Lastly, a review of the risk table shows the encounter qualifies as moderate risk based on the presenting problems of “two or more stable chronic illnesses.” For MDM, only two out of three factors must meet or exceed any given level to select the level. In this case, high complexity presenting problems and moderate risk qualify this visit as moderate MDM.

Based on the code description for code 99214 that two of three components are required for established patients, a detailed history and moderate complexity MDM meet the requirements for 99214.

Using the 1997 Guidelines, the level of history and level of MDM do not change and this encounter would still be documented as 99214.

ICD-9-CM Diagnosis Codes
428.0 Congestive heart failure, unspecified
250.00 Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled
272.4 Other and unspecified hyperlipidemia; hyperlipidemia NOS
716.96 Arthropathy, unspecified; arthritis - (acute) (chronic) (subacute)

In the alphabetic index, under the main term, Failure and subterms, heart and then congestive, the coder is directed to see code 428.0. Confirmation is made by reviewing the code in the tabular section as well. For diabetes mellitus type II, under the main term, Diabetes, the coder is directed to 250.0 with a fifth-digit subclassification for type II not stated as uncontrolled of 0. Confirmation is made by reviewing 250.00 in the tabular section.

Also in the alphabetic index, the main term Hyperlipidemia directs the coder to 272.4. Confirmation is made by reviewing the code in the tabular section. For arthritis, under the main term, Arthritis (acute) (chronic) (subacute), the coder is directed to 716.9 with fifth-digit subclassification of 0-9. Fifth-digit subclassification of 6, for lower leg, is selected for arthritis of the knee. Confirmation is made by reviewing the code in the tabular list under 716.9.

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