A 28-year-old female patient is returning to her provider’s office with complaints of RLQ pain and heartburn with a temperature of 100.2. The provider performs a detailed history, detailed exam and determines the patient has mild appendicitis. The provider prescribes antibiotics to treat the appendicitis in hopes of avoiding an appendectomy. What are the correct CPT® and ICD-10-CM codes for this encounter?

The options:

a.99202, R10.31, K37

b.99213, K37

c.99214, K37, R12

d.99203, R50.9, R12, R10.31, K374

The CORRECT ANSWER IS c.

c.99214, K37, R12

Explanation:

This is a confirmed patient E/M level of service which comes as a result of the signs and symptoms which made her check back to her provider for the appointment.

Code 99214 is suitable in cases where two out of three essential units are met for a confirmed patient.

Based on the ICD-10-CM guidelines I.B.4., an important diagnosis is stated and recorded after its confirmed.

On careful examination of the ICD-10-CM Alphabetic Index for Appendicitis which leads us to K37.

Guideline I.B.5 pinpoints to whatever Clinical manifestations seen to be a key part of the important diagnosis/disease activities.

Heartburn can not be regarded as a symptom often observed with appendicitis. Thus, we can record this using an extra code, references to guideline I.B.6.

From the guideline I.B.6 the Alphabetic Index for Heartburn would guide us straight to R12.