Hospital inpatient and observation care services (99221-99236) are selected based on the level of medical decision-making. In this scenario, reporting a code from the initial hospital inpatient and observation care services would be most appropriate (99221-99223), as the documentation indicates the patient is being admitted. When leveling this service, consider that the patient has an acute illness with systemic symptoms (pneumonia) and a stable, chronic illness (HIV). Labs were reviewed to confirm the diagnosis, and a decision was made to admit the patient into observation. Therefore, the final level of medical decision-making is moderate, making the E/M code 99222. Even though pneumonia is the reason for admission, ICD-IO-CM guidelines stipulate that a confirmed HIV diagnosis takes precedence in sequencing when the reason for admission is HIV related.

0484T describes a transcatheter mitral valve replacement via a thoracic approach. CPT code
33430 describes a mitral valve replacement in which cardiopulmonary bypass is initiated. CPT code
0483T describes a transcatheter mitral valve replacement with a percutaneous approach: however, the documentation identifies a transthoracic incision. Catheterization is bundled into the procedure and is not separately identifiable unless the provider documents extenuating circumstances (i.e. no prior study available, inadequate visualization, etc.).

An E/M is always billed when a patient is seen in the emergency department because it is unscheduled and urgent. In this case, the documentation encompasses a straightforward level of decision-making (one acute, uncomplicated injury, minimal or no data reviewed, superficial dressings that result in minimal risk or morbidity of the patient), which lead the coder to 99282.
Modifier 57 is appended to indicate that the decision for surgery was made just prior to the procedure and is not bundled. CPT coding crosswalk confirms that a closed treatment of a dislocated elbow is CPT code 24600. Application ofa splint is represented by CPT code 29105 but is not applicable when performed with a surgery to correct the dislocation. ICD-IO-CM crosswalk for dislocation of left elbow is S53.105A.

Epinephrine is listed in alphabetical order in the HCPC book under "Table of Common Drugs." The documentation reflects a dosage of 0.3 mg, so three units of 0.1 mg epinephrine 00171) should be reported. The injection of the medication is reported with CPT code 96372 and includes an inherent E/M component unless the provider goes beyond the normal assessment of the patient prior and/or after administration of a drug.

Toxic adenoma E05.2- is a thyroid nodule that may secrete hormones into the body that results in an overactive thyroid. Graves' disease E05.0- is an autoimmune disorder that attacks the thyroid, resulting in overactivity. Hashimoto's disease E06.3 is also an autoimmune disorder:
however, it usually results in an underactive thyroid. Acosta disease T 70.29- is altitude sickness.
Even if a coder is unfamiliar with these terms, by locating the ICD-IO-CM code that correlates to the condition, a coder can infer which body system a diagnosis relates to.