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 codes are C79.51 for secondary malignant neoplasm of bone and bone marrow (indicating the metastasis to the sacral vertebrae) and Z85.46 for personal history of malignant neoplasm of prostate (indicating the patient's history of prostate cancer). The correct CPT code is 99205, which represents a new patient office or other outpatient visit that requires a comprehensive history, a comprehensive examination, and medical decision making of high complexity, fitting the description of the physician's actions.

Mr Jones, a New Patient with a History of Prostate