CPT E&M Code and ICD-10 Diagnostic Codes

Use your lecture materials to determine what CPT E&M Code and ICD-10 diagnosis code to utilize for this ‘new patient’ encounter using the medical decision-making (complexity) approach.
Provide justification for the code you assigned by including the following information in your discussion:
Case:
This patient presents to a local health center. As the provider, you must conduct a full physical on the patient as well as a psychiatric intake.
Liam is a 22-year-old who reports to you that he feels depressed and is experiencing a significant amount of stress about school, noting that he’ll “probably flunk out.” He spends much of his day in his dorm room playing video games and has a hard time identifying what, if anything, is enjoyable in a typical day. He states once he leaves the room he begins sweating and feels as if he has heart palpations. He rarely attends class and has avoided reaching out to his professors to try to salvage his grades this semester. Liam has always been a self-described shy person and has had a very small and cohesive group of friends from elementary through high school. Notably, his level of stress significantly amplified when he began college. You learn that when meeting new people, he has a hard time concentrating on the interaction because he is busy worrying about what they will think of him – he assumes they will find him “dumb,” “boring,” or a “loser.” When he loses his concentration, he stutters, is at a loss for words, and starts to sweat, which only serves to make him feel more uneasy. After the interaction, he replays the conversation over and over again, focusing on the “stupid” things he said. Similarly, he has a long-standing history of being uncomfortable with authority figures and has had a hard time raising his hand in class and approaching teachers. Since starting college, he has been isolating more, turning down invitations from his roommate to go eat or hang out, ignoring his cell phone when it rings, and habitually skipping class. His concerns about how others view him are what drive him to engage in these avoidance behaviors. After conducting your assessment, you give the patient feedback that you believe he has social anxiety disorder, which should be the primary treatment target. You explain that you see his fear of negative evaluation, and his thoughts and behaviors surrounding social situations, as driving his increasing sense of hopelessness, isolation, and worthlessness.
Significant Symptoms:
• Anxiety
• Depression
• Ruminations
• Social Anxiety
• Physical symptoms; sweating, heart palpations
Vitals:
127/80
98
18
60
90%
BMI 30
225 lbs
72”
Physical exam:
General: Well appearing, well-nourished, in no distress. Oriented x 3, normal mood and affect. Ambulating without difficulty.
Skin: Good turgor, no rash, unusual bruising, or prominent lesions
Hair: Normal texture and distribution.
Nails: Normal color, no deformities
HEENT: Head: Normocephalic, atraumatic, no visible or palpable masses, depressions, or scaring. Eyes: Visual acuity intact, conjunctiva clear, sclera non-icteric, EOM intact, PERRL, fundi have normal optic discs and vessels, no exudates or hemorrhages
Ears: EACs clear, TMs translucent & mobile, ossicles nl appearance, hearing intact.
Nose: No external lesions, mucosa non-inflamed, septum, and turbinates normal
Mouth: Mucous membranes moist, no mucosal lesions.
Teeth/Gums: No obvious caries or periodontal disease. No gingival inflammation or significant resorption. Pharynx: Mucosa non-inflamed, no tonsillar hypertrophy or exudate
Neck: Supple, without lesions, bruits, or adenopathy, thyroid non-enlarged and non-tender
Heart: No cardiomegaly or thrills; regular rate and rhythm, no murmur or gallop
Lungs: Clear to auscultation and percussion
Abdomen: Bowel sounds normal, no tenderness, organomegaly, masses, or hernia
Back: Spine normal without deformity or tenderness, no CVA tenderness
Rectal: Normal sphincter tone, no hemorrhoids or masses palpable
Extremities: No amputations or deformities, cyanosis, edema or varicosities, peripheral pulses intact
Musculoskeletal: Normal gait and station. No misalignment, asymmetry, crepitation, defects, tenderness, masses, effusions, decreased range of motion, instability, atrophy or abnormal strength or tone in the head, neck, spine, ribs, pelvis or extremities.
Neurologic: CN 2-12 normal. Sensation to pain, touch, and proprioception normal. DTRs normal in upper and lower extremities. No pathologic reflexes.
Psychiatric: Oriented X3, intact recent and remote memory, judgment and insight, anxious mood and affect.
Breast: No nipple abnormality, dominant masses, tenderness to palpation, axillary or supraclavicular adenopathy.
G/U: Penis circumcised without lesions, urethral meatus normal location without discharge, testes and epididymides normal size without masses, scrotum without lesions.

  1. The level of medical complexity encompassed by including the number of points for the diagnoses/management options and the amount/complexity of data reviewed; then identify the level of risk for complications, morbidity, mortality
  2. In the discussion explore how the ICD-10 Codes that you assigned impact third-party payor reimbursement for this visit.
    Responses need to address all components of the question, demonstrate critical thinking and analysis and include peer-reviewed journal evidence to support the student’s position.
    Please be sure to validate your opinions and ideas with citations and references in APA format.
    Your initial response is due by Wednesday at 11:59 pm CT.
    Estimated time to complete: 2 hours
    Peer Response
    Instructions:
    Please read and respond to at least two of your peers’ initial postings. You may want to consider the following questions in your responses to your peers:
    • Compare and contrast your initial posting with those of your peers.
    • How are they similar or how are they different?
    • What information can you add that would help support the responses of your peers?
    • Ask your peers a question for clarification about their post.
    • What most interests you about their responses?

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Sample Answer

 

 

 

CPT and ICD-10 Coding for Liam’s Case

Medical Decision Making and CPT Code Selection

This case involves a new patient with a complex presentation of social anxiety disorder (SAD), depression, and physical symptoms like sweating and heart palpitations. A comprehensive history, physical exam, and assessment are necessary to establish a diagnosis and treatment plan.

Based on the HPI (history of present illness) and the extent of the evaluation, this encounter likely qualifies for a 99203 (Level 3) E/M code using the medical decision-making (MDM) pathway. Here’s a breakdown of the MDM components:

Full Answer Section

 

 

 

  • History: Detailed history of social anxiety symptoms, depression, and avoidance behaviors; explores onset, triggers, and impact on daily life (complex).
  • Examination: Comprehensive physical exam with normal findings, but relevant to ruling out medical causes of anxiety (comprehensive).
  • Medical Decision Making: Four elements are considered:
    • Number of Data Points: History, exam findings, BMI calculation, potential diagnoses (SAD, depression, possible somatic anxiety) contribute multiple data points (extensive).
    • Complexity of Data Review: Analyzing the relationship between social anxiety, depression, and physical symptoms requires complex data review.
    • Risk of Complications: While social anxiety and depression don’t pose immediate physical risks, potential complications like self-harm or substance abuse need consideration (moderate).
    • Patient Management: Developing a treatment plan for SAD and depression, including potential medication and psychotherapy, involves moderate complexity.

Considering these factors, a Level 3 E/M code (99203) is justified.

ICD-10 Diagnosis Codes

The primary diagnosis for this case is:

  • F40.11 – Social Anxiety Disorder (Generalized)

Secondary diagnoses include:

  • F32.1 – Major Depressive Disorder, Single Episode (if criteria are met for a depressive episode)
  • R45.40 – Unspecified Problem Related to Education

ICD-10 Codes and Reimbursement

ICD-10 diagnosis codes impact reimbursement by influencing the severity and complexity of the condition documented. Here’s how the chosen codes affect reimbursement in this case:

  • F40.11 (Social Anxiety Disorder): This diagnosis generally carries a higher reimbursement rate than a simple diagnosis like “anxiety unspecified” because it reflects a more specific and complex condition.
  • F32.1 (Major Depressive Disorder): Adding depression as a secondary diagnosis may further increase reimbursement if appropriate criteria are met, reflecting the additional complexity of managing two conditions.
  • R45.40 (Unspecified Problem Related to Education): This code may have minimal impact on reimbursement but provides context for the social anxiety symptoms triggered by the academic setting.

References:

 

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