CODING & DOCUMENTATION
Fam Pract Manag. 2020 Nov-Dec;27(6):45.
Author disclosure: no relevant financial affiliations disclosed.
- SUSPECTED EXPOSURE TO COMMUNICABLE DISEASE
- DIABETES TYPE 1.5
- REMOTE PATIENT MONITORING
- TETANUS IMMUNIZATION DUE TO INJURY
- PERFORMING VENIPUNCTURE ON A CHILD
SUSPECTED EXPOSURE TO COMMUNICABLE DISEASE
What diagnosis code should I report when a patient has suspected exposure to a communicable disease, but has no symptoms or negative test results?
Report a code from category Z20 for an encounter with an asymptomatic patient who requests evaluation due to contact with and (suspected) exposure to a communicable disease. Category Z20 includes codes for various infections, such as those caused by meningococcus, E. coli, tuberculosis, viral hepatitis, HIV, and other bacteria and viruses. For COVID-19, use Z20.828, “Contact with and (suspected) exposure to other viral communicable diseases.” The Z20 codes are for patients suspected to have been exposed to disease by close personal contact with an infected individual, or those in an area where a disease is epidemic.
DIABETES TYPE 1.5
An endocrinologist diagnosed my patient with type 1.5 diabetes during hospitalization. I am providing care management for all of her chronic conditions. What diagnosis code should I report for her diabetes?
Report a code from category E13 (other specified diabetes mellitus) for patients diagnosed with type 1.5, combined, or dual diabetes. Also assign a code to indicate management with long-term oral hypoglycemic drugs (Z79.84) or insulin (Z79.4), and add Z79.899 when an injectable GLP-1 receptor agonist drug is prescribed for long-term use in addition to either an oral hypoglycemic drug or insulin.
REMOTE PATIENT MONITORING
CPT codes 99091 and 99457 appear to be for similar remote patient monitoring services. When is each code used?
Use code 99091 when a physician or other qualified health professional (QHP) personally collects and interprets physiologic data that is stored digitally or transmitted by a patient over a 30-day period. The physician or QHP must spend at least 30 minutes providing
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