Chapter 19: CPT® Section Evaluation & Management Workbook Case 1 Answers and Rationale.

Identification: The patient is a 37-year-old Caucasian lady.
Chief Complaint: The patient is here today for follow up |1| of lower extremity swelling. |2|

History of Present Illness: A 37-year-old with a history of dyslipidemia and chronic pain. |3| The patient is here for follow up of bilateral lower extremity swelling. The patient tells me the swelling responded to hydrochlorothiazide.

Exam: Very pleasant, no acute distress (NAD). Vitals: P: 67, R: 18, Temp 98.6, BP: 130/85.

Data Review: I did review her labs |4| and echocardiogram. |5| The patient does have moderate pulmonary hypertension.

1. Bilateral lower extremity swelling: Improved with diuretics; this may be secondary to problem #2. |6|
2. Pulmonary hypertension: |7| Etiology is not clear at this time, will do a workup and possible referral to a pulmonologist.

Plan: I think we will need to evaluate the etiology of the pulmonary hypertension. The patient will be scheduled for a sleep study. |8|

|1| This is an established patient and an established problem.
|2| Chief complaint.
|3| Although dyslipidemia and chronic pain are listed as a history, there is no documentation to support the conditions were treated at this encounter or that they affected the management of the current conditions. These conditions are not coded and are not taken into consideration for the level of medical decision making.
|4| Labs were reviewed; however, the labs are credited at the time the labs were ordered. No credit given for MDM.
|5| An echocardiogram is reviewed. The echocardiogram is credited at the time it was ordered. No credit given for MDM.
|6| The extremity swelling is possibly due to pulmonary hypertension, but not certain, so it is coded separately for the diagnosis.
|7| Acute illness with systemic symptoms.
|8| A sleep study is ordered.

What are the CPT® and ICD-10-CM code(s) reported?
CPT® code: 99213
ICD-10-CM codes: M79.89, I27.20

CPT® code: Subcategory — Office visit, established patient, coded using 2021 E/M guidelines

Number and complexity of problems addressed: Pulmonary hypertension can be a serious condition. The provider suspects the patient’s swelling is a result of the pulmonary hypertension. It is not confirmed at this time, but it is something the provider is going to investigate further. This is considered an acute illness with systemic symptoms, making this moderate for the number and complexity of problems addressed.

Amount and complexity of data to be reviewed and analyzed: In this case, the provider reviews labs and an echocardiogram, and orders a sleep study. Because this is a follow up patient and a follow up condition, and there is no indication the labs and echocardiogram were ordered by another provider, there is no credit given for these. The provider orders one unique test (the sleep study), making this Minimal for the amount and complexity of data to be reviewed and analyzed.

Risk of complications and morbidity or mortality of patient management: Further study (additional testing) is needed to determine the cause of the pulmonary hypertension. There is low risk involved in a sleep study. The risk associated with the problem of pulmonary hypertension was given in the number and complexity of problems addressed. The risk of patient management is low.

ICD-10-CM codes: The bilateral lower extremity swelling is possibly due to the pulmonary hypertension, but it is not confirmed so it is coded separately. In the ICD-10-CM Alphabetic Index, look for Swelling/leg/lower referring you to M79.89. For the pulmonary hypertension, look in the Alphabetic Index for Hypertension, hypertensive/pulmonary referring you to I27.20. Verify code selections in the Tabular List.