WEEK 10: Medical Emergencies
Lesson 3: Coding
Assignment 10.3 : Coding
Introduction
By the end of this assignment, you will be able to:
• Determine the correct CPT and ICD-10 given a scenario. (CO2, CO9)
• Demonstrate accuracy and integrity of the electronic medical record. (CO2, CO9)
Assignment Guidelines
Review the scenario provided and complete the assessment and plan for the patient presented below:
Coding Assignment
History of Present Illness: The patient is a 45-year-old female who is coming in for a prescription refill of lisinopril. She has been compliantly taking this medication for several years and denies any side effects (i.e. cough). She has been hypertensive for 15 years, following her third pregnancy.
Past Family/Social History: n/a
Review of Systems: Denies any CP, SOB, or leg swelling
Physical Exam:
BP 134/84 Pulse 80 and regular
Assessment
1. _________ Hypertension
Plan
1. Continue on same dose – refill sent to pharmacy of patient’s choice
2. Total time spent with patient 10 minutes
CPT _____________
Review the following information in preparation for Week 10 Assignment 10.3: Coding.
CPT Codes and ICD-10 Codes
What Are CPT Codes and ICD-10 Codes?
• International Classification of Disease Codes: ICD-10 codes are used to identify the “why” of a patient who is being seen, whether it is for an injury, illness, or other medical conditions. It is how healthcare providers communicate with the health insurance companies for standardized payment.
• Current Procedural Terminology: CPT codes are used to describe the type of services that medical professionals perform along with any procedures.
The relationship between ICD-10 codes and CPT is important. The ICD-10 code will justify the level of the CPT code and any procedures performed so that the visit will be covered and the provider will be reimbursed.
Tables
The following established and new patient coding tables will assist you in completing Week 10 Assignment 10.3: Coding.
• Established Patients Coding Table 1
• New Patients Coding Table 2
Established patients coding: Table 1
Established patients coding: Table 1
Code History Exam Medical Decision Making Typical Face-to-Face Time RVU
99211 Not required Not required Not required 5 0.26
99212 Problem-focused Problem-focused Straightforward 10 0.72
99213 Expanded problem-focused Expanded problem-focused Low 15 1.44
99214 Detailed Detailed Moderate 25 2.22
99215 comprehensive comprehensive High 40 3.14
New patients coding: Table 2
New patients coding: Table 2
Code History Exam Medical Decision Making Typical Face-to-Face Time RVU
99201 Problem-focused Problem-focused Straightforward 10 0.76
99202 Expanded problem-focused Expanded problem-focused Straightforward 20 1.43
99203 Detailed Detailed problem-focused Low 30 2.17
99204 Comprehensive Comprehensive Moderate 45 3.67
99205 Comprehensive Comprehensive High 60 4.78
The book used for this class and for this assignment is cited here:
Buttaro, T., Trybulski, J., Bailey, P., & Sandberg-Cook, J. (2021). Primary care: Interprofessional collaborative practice (6th ed.). St. Louis, MO: Elsevier Mosby.
RUBRIC
Criteria Ratings
Correct ICD 10 Codes Meets Expectations
Correct CPT Code Meets Expectations
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