Question

Code the procedures/services, and diagnosis(es) for the following case scenario. Be sure to include all necessary CPT and/or HCPCS modifiers. A 66-year-old Medicare patient came to the office for his annual physical. He has a past history of hypertension, controlled by medication, and new complaints of dizziness and tiredness (which the physician determined was related to today's increased blood pressure). During the course of the examination, the physician found blood pressure of 160/130. A detailed history and exam of this established patient was performed in addition to the preventive medicine encounter. Procedure/Service: Preventive medicine, established patient, age 66. Enter code: Diagnosis: Annual exam. Enter code: Procedure/Service: Outpatient, established patient, level 4. Enter code: Diagnosis: Hypertension.

Answer 1

E/M code :
Detailed patient history and exam for the established patient - 99214
CPT code:
Preventive medicine service for established patient -99397(It include history, examination, counseling, risk factor reduction intervention, lab, diagnostic procedure)
ICD-10-code
Hypertension - I10