A 38-year-old insulin-dependent established patient called his physician complaining of having some rectal bleeding after using the bathroom. The physician agreed to meet the patient in the outpatient department of the hospital. The physician performed an expanded problem-focused history with a detailed examination. The patient is to have blood work and a stool culture and is to be scheduled for a lower GI series. The physician's diagnosis was Hematochezia etiology unknown. Select the appropriate CPT and ICD-10-CM codes.

Question

Quizplus · Accepted Answer

99214 is the correct CPT code for an office or other outpatient visit that includes an expanded problem-focused history and a detailed examination. K92.1 (Hematochezia), E11.9 (Type 2 diabetes mellitus without complications, as the patient is insulin-dependent it's assumed to be type 2 unless specified otherwise), and Z79.4 (Long term (current) use of insulin) are the correct ICD-10-CM codes for the diagnosis and patient condition described.

A 38-Year-Old Insulin-Dependent Established Patient Called His Physician Complaining of Having