Coding Corner Answer

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The correct way to code this visit is: 99214-25, 20610, J7322 with the diagnoses of 715.96, 787.02.

This encounter is coded as 99214 because it included:

• Detailed history—extended history of present illness, extended review of systems, one past family and social history;
• Comprehensive examination—eight systems; and
• Medical decision making—moderate complexity (established problem, new problem no additional workup; new prescription drug ordered).

The intraarticular injection of the right knee would be coded 20610.

Note: The office visit is allowed because the knee injection was a separate and significant problem the patient presented at the time of the visit.