An established patient presents to the office with an acute, deep cough, along with wheezing. The patient has a history of allergies along with chronic rhinitis. After an expanded problem-focused exam, the physician learns that the patient's home has just been found to have mold in the walls. The physician has spent an additional 15 minutes providing resources and counseling with the patient regarding the effects of mold and treatment of his URI. The physician has also recommended lab tests and x-rays. Select the appropriate CPT and ICD-10-CM codes.

Question

Quizplus · Accepted Answer

The CPT code 99213 is appropriate for an established patient with an expanded problem-focused exam and additional counseling. The ICD-10-CM codes J06.9 (acute upper respiratory infection), Z77.120 (contact with and exposure to mold), and Z87.09 (personal history of other diseases of the respiratory system) are relevant to the patient's condition and history.

An Established Patient Presents to the Office with an Acute