A 38-year-old female has severe low back pain due to a trauma injury she experie
ID: 126843 • Letter: A
Question
A 38-year-old female has severe low back pain due to a trauma injury she experienced as a factory worker 4 years ago. The chronic pain has become almost unbearable, and her internal medicine physician cannot go any further with her treatment. An initial outpatient consultation is requested and the patient is sent to see the pain management specialist for suggestions to control the chronic pain. A comprehensive history is taken, including all pertinent information regarding her injury. During the comprehensive examination the patient’s gait and movement are observed. Moderate-complexity decision making is performed, including different treatment options. A separate note is dictated to show the requesting physician what results were found during the visit and the decision on treatment of her pain.
CPT Code:__________
ICD-10-CM codes: ________, ___________
Explanation / Answer
The codes according to the Condition of the 38 year old female are
CPT CODE - 99244
ICD - 10- CM CODE - Z71. 9 and M54. 9.