Question

A 10-year-old girl, presents with a sore throat, fever of 101.4F, swollen glands in the neck, and a red blotchy rash over the neck, face, chest, and back. She has significant nausea and has vomited three times since this morning and is complaining of severe pain when swallowing. A detailed history and examination are documented, with medical decision making of moderate complexity. The physician ordered a rapid strep test, which was performed in the office and was positive. Because of the significant nausea and questionable antibiotic compliance in the past, the physician administers 1.2 million units of Bicillin L-A (long-acting Penicillin G benzathine) via a deep intramuscular injection. The patient will be seen again in five days. Diagnoses were documented as strep throat with scarlatina.
Required:
Assign the codes, including E/M codes and laboratory codes, for this case.

Answer 1

Three different types of codes (ICD-10 , CPT, HCPCS) are assigned for this case including E/M codes and laboratory codes

Three different types of codes must be reported for office visits: ICD-10 codes for diagnoses that includes  A38.8, J02.0, CPT codes (including E/M codes for procedures) that includes 99214, 87880, 96372, and HCPCS codes that includes J0561 × 12 for medical supplies used during the appointment.

Codes in ICD-10:

Scarlet fever with additional complications, A38.8

CPT Codes for J02.0 Streptococcal pharyngitis:

99214 Evaluation and management of an established patient during an office or other outpatient visit that calls for at least two of the following three essential elements:

- A thorough history;

- A thorough investigation;

- Moderately complicated medical decision-making.

87880 Streptococcus, group A, infectious agent antigen detection by immunoassay with direct optical observation (This is the code for the rapid strep test)

96372 Subcutaneous or intramuscular administration of a chemical or medicine for treatment, prevention, or diagnosis

Code HCPCS:

J0561 X 12

Penicillin G benzathine injection, J0561, 100,000 units (This is the code for the Bicillin L-A administered).We divide the doctor's 1.2 million Bicillin L-A units used by 100,000 to get the 12 doses we need to report (J0561 X 12).

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