Medicine

 90281-90399- serum globulins and immune Category/ Location

globulins 1. Office
o = substance/ products - new
 administration code - established
o 96365 2. Observation
o 96366 - initial observation ( 1st day of observation
o 93667 status)
- subsequent observation - 2nd, 3rd, 4th
o 93668
3. In patient- "admit"
o 93669
- initial - 1st day of admission
o 93670
- subsequent- 2nd, 3rd, 4th..
o 93671 4. Observation or inpatient care services (
o 93672 99234-99236)
o 93674 -observation status
o 93675 -same day discharge
*modifier 51- should not be reported 5. Consultation
- Immunization/ vaccine product code + - office consultation
Administration code = min. of 2 codes - in patient consultation
6. Emergency department (ED)
 90476-90746- vaccine/ toxoid Critical Care Services
- = substance/ products 99291-99292
 administration code Example:
- 90460 100 minutes critical care = 99291, 99292
- 90461 120 minutes critical care =99291, 99292 x2
- 90471-90474 7. Nursing Facility
*modifier 51- should not be reported SNF- skilled nursing facility
Examples: ICF-Intermediate care facility
1. DTap given intramuscularly to a 6-year-old LTCF- Long term care facility
b. 90700, 90471 Psychiatric residential treatment center
2. A pregnant female is Rh negative and at 28 Initial nursing facility
weeks gestation. The child's father is Rh Subsequent
positive. The mother is given an injection of 3 Key components
a high-titer Rho(D) immune globulin. 300 1. History
mcg, IM 2. Examination
c. 90384, 96372 3. Medical decision making
3. A 10-year-old patient received a mumps, Examples:
measles, rubella and varicella (MMRV) 1. The patients is a 35-year-old male who
injection at a neighborhood clinic with presents to the ED after several hrs of low back
provider counseling. pain, nausea and chills. The ED physician takes
d. 90710. 90460, 90461x3 a detailed history and performs a detailed
examination. A urinalysis and CT of the
Evaluation and management (E/M) abdomen is ordered. The results of the CT show
1st step: Determine the catergory/ subcategory 2 small kidney stones. The ED physician
-location of the service discusses the result with the patient and tells him
the stone are small and will pass on their own.
Medical decision making (MDM) of moderate
complexity is made with the patient being
discharged, with a prescription of pain
medication, and with a diagnosis of kidney
stones.
99284
2. ED= 99281
Problem focused hx
problem focuses exAM
low complexity decision making
3. ED= 99283- code to the lowest
Expanded problem focused history
detailed exam
Moderate decision making
4. ED= 99282
Expanded problem focused history
detailed exam
High complexity
 Meds given:
 Extent of hx:
 extent of examination:
 number of test ordered:
 supplies used:

1. History Elements
History of present b. ROS review of systems
a. HPI
illness