Case Examples of Coding
An established patient presents for a 12-month well-child-checkup. Three immunizations are given and fingerstick screening for anemia is done.
CPT 99392 Preventive medicine, 1-4 years old.
CPT 90471 Immunization administration, first
CPT 90472 X 2 Immunization administration, additional
CPT 90707 MMR vaccine (charge for the vaccine itself, not for giving it)
CPT 90713 I PV vaccine
CPT 90716 Varicella vaccine
CPT 85013 Hemoglobin testing
CPT 36415 Venipuncture (Even though a fingerstick was performed, checking the code for venipuncture reveals that it includes finger/heelsticks as well.)
ICD-9-CM Diagnosis: V20.2 (well child)
An adult male presents for the first time to your office with new-onset hypertension.
CPT 99204 E&M, new patient, level IV
(The level could change, depending on the exact nature of his problems)
ICD-9-CM Diagnosis: 401.0 (hypertension)
An adult female established patient presents for repair of a 3-cm laceration on the left arm
CPT 12002 Simple laceration repair, 2.6 to 7.5 cm
ICD-9-CM Diagnosis: 881.0 (laceration of elbow, forearm, wrist)
Medscape Med Students. 2001;3(2) © 2001 Medscape
Cite this: Coding and Documentation: A Brief Guide - Medscape - Sep 12, 2001.