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A patient presents to the physicians office for the first time with nausea and vomiting. The physician performs a detailed history. Also supported by documentation is an eight organ system comprehensive exam and moderate medical decision making. Physician assesses the patient with acute gastritis. What are the appropriate E/M and ICD-10-CM codes for this service?
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2. A physician prescribes digoxin to treat a patient with congestive heart failure. After six months, the physician performs a total digoxin blood test to monitor the level of the drug. What lab code(s) should be used for the six month evaluation?
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Rationale:The provider documented a detailed history. An eight organ system exam supports a comprehensive exam. The medical decision making is moderate. This is a new patient with a detailed history, comprehensive exam and moderate medical decision making which supports 99203. The patient is diagnosed with acute gastritis. When a definitive diagnosis is determined, do not report the associated signs and symptoms (See ICD-10-CM guideline I.B.5.). In the ICD-10-CM Alphabetic Index look for Gastritis, acute and you are referred to K29.00. There is no mention of a hemorrhage. Verify in the Tabular List.
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Rationale:The lab test being performed is a therapeutic drug assay to monitor the level of digoxin. From the CPT Index look up Therapeutic Drug Assay, Digoxin.
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