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

The correct CPT code for an established patient's office visit with an expanded problem-focused history and detailed examination is 99214. The ICD-10-CM codes are K92.1 for Hematochezia, E11.9 for Type 2 diabetes mellitus without complications (since the patient is insulin-dependent, it's assumed to be Type 2 diabetes unless specified otherwise), and Z79.4 for long-term (current) use of insulin.

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