In this case, for generic pneumonia, the code is J18.9. For each of the patient’s conditions, he’d consult the ICD-10-CM Health Care Code Sets for Outpatient Billing. Jim would circle the keywords in the information received, including the patient’s medical diagnosis, treatment, and equipment or medication provided, if any. Jim would encode that report using the following process: In the office, the physician provided and interpreted a two-view chest X-ray. The physician performs a detailed history, detailed examination, and medical decision-making of moderate complexity. Let’s say a medical coder, Jim, received the following information:Ī patient is seen in the office for a chief complaint of shortness of breath and fatigue. For example, the code might be 99203 for an initial office visit, while 99203-57 describes an initial office visit with a decision for surgery.ĭid you know? The process for telemedicine billing is the same as billing for in-office patients. If one of these situations occurs, coders add a two-digit alphanumeric modifier to the code.
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