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 for this scenario is 99214, which represents an office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a detailed history, a detailed examination, and medical decision making of moderate complexity. The scenario describes a detailed examination and high complexity decision making, fitting the requirements for 99214 more closely than 99215, which requires high complexity in all three areas. The ICD-10-CM codes are E09.9 for drug or chemical induced diabetes mellitus without complications (due to taking oral corticosteroids), M06.9 for rheumatoid arthritis without specification, and Z79.52 for long term (current) use of systemic steroids. The choice of E09.9 over E11.9 is due to the diabetes being induced by corticosteroids, not being a primary condition.

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