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 established patient office visit that includes an expanded problem-focused history and detailed examination, which matches the scenario described. K92.1 (Hematochezia) is the correct ICD-10-CM code for the diagnosis given. E11.9 (Type 2 diabetes mellitus without complications) is appropriate for an insulin-dependent patient, assuming type 2 diabetes due to the patient's age and the lack of specification of type 1. Z79.4 (Long term (current) use of insulin) is correct for a patient who is insulin-dependent.

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