Question

S: A new patient was seen today in the GI clinic for a level 2 visit. She complains of one week of severe epigastric pain and burning, especially after eating.

O: On examination there is extreme guarding and tenderness, epigastric region, with no rebound. Bowel sounds are normal.

A: Rule out gastric ulcer.

P: The patient is to have upper gastrointestinal series. Start on Zantac and eliminate alcohol, fried foods, and caffeine. Return to clinic in one week.

What are the CPT/HCPCS and ICD-10-CM codes for this situation?

Answer 1

ICD-10-cm
A patient diagnosed as gastric ulcer
Gastric ulcer - K25.9
CPT code
Level II new patient focus on expanded problem-focused history, detailed problem -found exam, moderate complexity decision making history.
A new patient is seen today in the GI clinic for level 2 visit -99202.