A 43-year-old female established patient diagnosed with rheumatoid arthritis comes to the office for her first infliximab infusion. The rheumatologist reviews the results of her labs, chest X-ray, and PPD test that were done the week prior to her procedure. The PPD and chest X-ray are negative. She reports still having some pain, stiffness, and swelling in her elbows, wrists, and most of her finger joints. She denies any fevers, cough, dyspnea, or concurrent illness. She is on a nonsteroidal antiinflammatory drug, weekly methotrexate subcutaneous injections, folic acid, and ranitidine. The physician performs an expanded problem-focused exam. No changes are made to her medications.
She is administered 50 mg of diphenhydramine as a prophylactic against any reaction to the infliximab. Her IV port is started at 10 a.m. and 200 mg of intravenous infliximab infusion started at 10:15 a.m. The infusion ended at 12:25 p.m.
How would you code this patient encounter?
