Coding and Documentation: A Brief Guide

Dipesh Navsaria, MPH, PA-C


September 12, 2001

In This Article

Case Examples of Coding

Case 1

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)

Case 2

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)

Case 3

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)