Chapter 19: CPT Evaluation & Management Section Workbook Case 4 Answers and Rationale.

Age: 33-year-old —Established patient

Vital Signs: TEMPERATURE: 98.9°F Tympanic, PULSE: 97 Right Radial, Regular, BP: 114/70 Right Arm Sitting, PULSE OXIMETRY: 98%, WEIGHT: 161 lbs.

Current Allergy List: Lortab

Current Medication List:
Lunesta Oral Tablet 3 Mg, 1 Every Day at Bedtime, As Needed
Prozac Oral Capsule Conventional 40 Mg, 1 Every Day
Levothyroxine Sodium Oral Tablet 100 Mcg, 1 Every Day for Thyroid
Meloxicam Oral Tablet 15 Mg, 1 Every Day for Joint Pain
Imitrex Oral Tablet 100 Mg, 1 Tab Po as Directed, Can Repeat After 2 Hours for migraines, Max 2 Per Day
Phenergan 25 Mg, 1 Every 4-6 Hours, As Needed for Nausea

Chief Complaint: Here for a comprehensive annual physical and pelvic examinations. |1|

History of Present Illness: Pt here for routine Pap and physical. Pt reports episode of syncope two weeks ago. Pt went to ER and had EKG, CXR and labs and says she was sent home and per her report everything was normal. She denies episodes since that time. She does occasionally have mild mid-epigastric discomfort but no breathing problems or light-headedness. Good compliance with her thyroid meds. |2|

Past Medical History: Depression.

Family History: No cancer or heart disease, mother has hypertension.

Social History: Tobacco Use: Currently smokes 1 1/2 PPD, has smoked for 15 to 20 years.

Review of Systems: Patient denies any symptoms in all systems except for HPI.

Physical Exam: |3|
Constitutional: Well developed, well-nourished individual in no acute distress.
Eyes: Conjunctivae appear normal. PERRLA
ENMT: Tympanic membranes shiny without retraction. Canals unremarkable. No abnormality of sinuses or nasal airways. Normal oropharynx.
Neck: There are no enlarged lymph nodes in the neck, no enlargement, tenderness, or mass in the thyroid noted.
Respiratory: Clear to auscultation and percussion. Normal respiratory effort. No fremitus.
Cardiovascular: Regular rate and rhythm. Normal femoral pulses bilaterally without bruits. Normal pedal pulses bilaterally. No edema.
Chest/Breast: Breasts normal to inspection with no deformity, no breast tenderness or masses. |4|
GI: Soft, non-tender, without masses, hernias or bruits. Bowel sounds are active in all four quadrants.
GU: External/Vaginal: Normal in appearance with good hair distribution. No vulvar irritation or discharge. Normal clitoris and labia. Mucosa clear without lesions. Pelvic support normal. |5|
Cervix: The cervix is clear, firm and closed. No visible lesions. No abnormal discharge. Specimens taken from the cervix for thin prep Pap smear. |5|
Uterus: Uterus non-tender and of normal size, shape and consistency. Position and mobility are normal. |6|
Adnexa/Parametria: No masses or tenderness noted.
Lymphatics: No lymphadenopathy in the neck, axillae, or groin.
Musculoskeletal exam: Gait intact. No kyphosis, lordosis, or tenderness. Full range of motion. Normal rotation. No instability.
Extremities: Bilateral Lower: No misalignment or tenderness. Full range of motion. Normal stability, strength and tone.
Skin: Warm, dry, no diaphoresis, no significant lesions, irritation, rashes or ulcers.
Neurologic: CNS II-XII grossly intact.
Psychiatric: Mood and affect appropriate.

Labs/Radiology/Tests: The following labs/radiology/tests results were discussed with the patient: Alb, Bili, Ca, Cl, Cr, Glu, Alk Phos, K, Na, SGOT, BUN, Lipid profile, CBC, TSH, Pap smear.

Assessment/Plan: Unspecified acquired hypothyroidism.

|1| Patient is seen for a routine Pap smear and comprehensive physical exam. This will be a preventive visit.
|2| Discussion of meds for thyroid. This is not sufficient enough to bill a problem visit along with the preventive visit.
|3| Comprehensive physical exam.
|4| Breast exam.
|5| Thin prep Pap smear collection.
|6| Pelvic exam.

What are the CPT® and ICD-10-CM code(s) reported?
CPT® code: 99395—for some insurance carriers, also code G0101 for the pelvic and breast exam.
ICD-10-CM codes: Z00.00, Z01.419, E03.9

Rationale:
CPT® code: Subcategory—Preventive Medicine Services, established patient. In the CPT® Index, look for Preventive Medicine/Established Patient referring you to code range 99382-99397.
Age 33—code 99395
Some insurance carriers will also allow reporting of HCPCS Level II code G0101 for the pelvic and breast exam. The Pap smear results were discussed with the patient during the visit indicating the Pap analysis was performed in the office. If the documentation included a Pap report, we could also bill for the Pap smear.

ICD-10-CM codes: In the ICD-10-CM Alphabetic Index, look for Examination/annual (adult) (periodic) (physical) referring you to Z00.00. Next, look for Examination/pelvic referring you to Z01.419. The provider also has documented unspecified acquired hypothyroidism. The provider confirmed her medication compliance, this can be listed as an additional code. In the Alphabetic Index, look for Hypothyroidism (acquired) referring you to E03.9. Verify codes in the Tabular List. Note: Some payers will require specific ICD-10-CM codes be reported with screening pelvic and breast exams. Check your payer policies.