A 38-year-old female has severe low back pain due to a trauma injury she experie

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.

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