Mr. Jones, a new patient with a history of prostate cancer 6 years ago, presented today with pain in his lower back and weakness in his extremities. He brought films from x-rays taken earlier in the week and his previous records from his internal medicine physician. The physician takes a comprehensive PMFSH and ROS and performs a comprehensive examination. Based on review of the records and his findings, the physician's diagnosis is metastatic prostate cancer to the sacral vertebrae. The physician discussed treatment options with the patient including risks and benefits. Select the appropriate ICD-10-CM and CPT code(s):

Question

Quizplus · Accepted Answer

The correct ICD-10-CM and CPT codes are C79.51 (Secondary malignant neoplasm of bone and bone marrow), Z85.46 (Personal history of malignant neoplasm of prostate), and 99205 (New patient office or other outpatient visit, which requires a comprehensive history, a comprehensive examination, and medical decision making of high complexity). The diagnosis of metastatic prostate cancer to the sacral vertebrae is coded as C79.51, and the history of prostate cancer is coded as Z85.46. The comprehensive services provided by the physician are best captured by 99205.

Mr Jones, a New Patient with a History of Prostate