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    Medicine AllergyImmun Slide14

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    Medicine AllergyImmun Slide14

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    Medicine_AllergyImmun_Slide14

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    239 views2 pages

    Medicine AllergyImmun Slide14

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    of 2

    Documentation Dissection

    Chief Complaint: Allergic Rhinitis (reaction of sneezing, red/watery eyes) |1|.

    Indications: Ms. Smyth is here for an allergy review. Otherwise doing well. She took her dog to the groomer and started having
    reactions of consistent sneezing with red and watery eyes |2|. Patient is currently on weekly allergy shots due to pollen and asthma |3|.
    However, the medication is not helping with the recent reactions.

    VITALS:
    Sitting RA BP: 103/75 (mmHg), Pulse rate: 76 (per min), Pulse Ox: 99(%), Height: 5’4”, Weight: 165 lbs 0 oz, BMI: 28/32, Peak
    Flow: 400.

    ALLERGIES: NKDA.

    Past Medical History:


    Positive for HX Unchanged.

    Social History:
    She never used recreational drugs. She never smokes. She never consumes alcohol.

    Family History:
    Family history of allergies, asthma, diabetes, hbp, heart disease.

    Assessment:
    Patient provided the allergy extract. Three injections were given. |4|.

    Plan:
    • Discussed results.
    • Return visit date: 4/21/20XX.
    • Reason for return visit: Assess clinical progress. Review medications and Monitor immunotherapy.
    • Stressed Compliance.
    • Immunotherapy scheduled weekly (maintain).

    _____________________________________________________________
    |1| Indication for testing.
    |2| Cause of the allergy.
    |3| Current immunology.
    |4| Patient provided the allergy extract. Number of injections documented.

    _____________________________________________________________

    What are the CPT® and ICD-10-CM codes reported?

    CPT® Code: 95117

    ICD-10-CM Code: J45.909

    Rationales:
    CPT®: The patient is seen for Immunotherapy Injections. In the CPT® Index, look for Immunotherapies, Allergen. There is a note
    that says see Allergen Immunotherapy. In the CPT Index, look for Allergen Immunotherapy/Allergenic Extracts/Injection referring

    1
    you to 95115, 95117. The CPT guidelines state 95115–95199 include professional services necessary for allergen immunotherapy.
    Documentation indicates that the patient provided the allergy extract, not the physician. CPT 95117 is correct—Professional
    services for allergen immunotherapy not including provision of allergenic extracts; 2 or more injections.

    ICD-10-CM: The patient has an allergy reaction due to animals and pollen and asthma. In the ICD-10-CM Alphabetic Index look
    for Allergy/Animal (dander) (epidermal) (hair) (rhinitis) leading to J30.81. Allergic Rhinitis due to animal (cat) (dog) hair and
    danger, J30.1 Allergic Rhinitis due to pollen. In the Tabular List at the beginning of Category J30 an Excludes1 note states J45.909 is
    excluded and never reported with the code referenced.

    In the ICD-10-CM Alphabetic Index look for Rhinitis/allergic/with asthma leading to J45.909. In the Tabular List for category code
    J45 includes note lists allergic rhinitis with asthma. This is the only code assigned.

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