John, age 45, was seen in the office today for interim medical evaluation and management of his type II diabetes. The physician performed an expanded problem-focused history and examination. At the same visit, the physician also administered a flu shot, split virus 0.5ml, intramuscularly. Select the appropriate CPT and ICD-10-CM codes.

Question

Quizplus · Accepted Answer

The correct CPT codes for this scenario are 99213 for the office visit for diabetes management, which is an expanded problem-focused history and examination, and 90471 for the immunization administration (first vaccine), along with 90658 for the flu shot itself. The correct ICD-10-CM codes are E11.9 for type II diabetes, unspecified, and Z23 for the encounter for immunization.

John, Age 45, Was Seen in the Office Today for Interim