Question

What is the professional code and the cpt ICD-10-cm code for this case? Office consultation CC: Hip pain. Four months status post right knee arthroscopy for medial meniscectomy and debridement of ACL tear. S: The patient has become symptom-free with regard to the knee I repaired, except for a feeling that his knee might want to give way when he goes up and down stairs. He has had no locking, catching, buckling or giving way. There is no swelling and there is really no pain. The patient is being sent as a new consult from Dr. A for his left hip, which is painful. It is painful with walking and with turning certain ways. It will catch and lock and the pain is primarily in the groin. There is no pain in the right hip. He has not been taking anything for the hip other than Tylenol for the pain, which provides little relief. No other musculoskeletal issues. General health otherwise is good except for hypertension, on HCTZ daily. Lives with his wife in a bi-level home. O: Examination of the left hip: The patient has marked loss of motion. He can flex to about 45 degrees. Internal rotation is 0 degrees, external rotation is 20 degrees. Extension, however, is full. Abduction is about 20 to 25 degrees. Adduction is 15 degrees. With regard to the right hip, his flexion is about 100 degrees, internal rotation is 10 degrees, external rotation is 30 degrees, and Abduction is 45 degrees. Adduction is 30 degrees. Examination of the knees reveals well healed surgical wound about the right knee. He has excellent range of motion. There is good stability, except for a slight hint of anterior drawer sign. Diagnostic Tests: Tests are reviewed. The x-rays of the hips done last week by his primary physician reveal he has a rather significant osteoarthritis of the left hip, and somewhat lesser osteoarthritis of the right hip. A: Osteoarthritis of the hips, bilaterally, left worse than right. Status post right knee arthroscopy for debridement of torn medial meniscus and debridement of stump of ACL tear. P: I have given him an order for an ACL brace and prescription for Ibuprofen 600 mg × 1, p.o. t.i.d., with two refills for the hip. I would like to see him back in a month for re-evaluation. If there is no improvement, will discuss the possibility of a joint injection to the hip. A copy of this report is to be sent to the requesint provider.

Answer 1

Here the case is an established patient already has got a consultation with a physician early.

Thus here the consultation is an office consultation with a :

• Comprehensive history
• Comprehensive examination
• Medical decision making of high complexity Presenting problem(s):
• Moderate to high severity
• Typical time: 40 minutes face-to-face with patient and/or family

Thus here we can apply the E/M CPT code as 99215

Here we can apply the ICD-10 code as :

M16.0: Arthrosis of hip, Primary coxarthrosis, bilateral