A 55-year-old established female patient was seen for management of uncontrolled diabetes due to taking oral corticosteroids for rheumatoid arthritis. She reported elevated glucose readings of 180, 210, 195, and 205 in recent weeks. The physician performed a brief history to update her record since the last visit, a detailed examination, and medical decision making of high complexity. He counseled the patient on diet and lifestyle factors and prevention of serious diabetic manifestations. He decided to start her on insulin to see how she responds. Select the appropriate CPT and ICD-10-CM codes.

Question

Quizplus · Accepted Answer

The correct CPT code is 99214 for an established patient with high complexity medical decision making. The ICD-10-CM codes are E09.9 for drug-induced diabetes mellitus without complications, M06.9 for rheumatoid arthritis, and Z79.52 for long-term use of systemic steroids.

A 55-Year-Old Established Female Patient Was Seen for Management of Uncontrolled