Question

Code the procedures/services, and diagnosis(es) for each of the following case scenarios. 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. Enter code:  

Answer 1

Procedure/Service: Preventive medicine, established patient, age 66. Enter code: 99381

Diagnosis: Annual exam. Enter code: 99369

Procedure/Service: Outpatient, established patient, level 4. Enter code: 99214

Diagnosis: Hypertension. Enter code: I10