Assign the appropriate CPT E & M level, procedures and ICD-10-CM code(s) for the physician office encounter. When there are multiple CPT codes, always sequence E & M level first. When there are multiple ICD-10-CM codes, sequence first-listed diagnosis first.

This patient was referred by her primary care physician due to complaints of muscle weakness and diplopia. The consulting physician documented a comprehensive history, a detailed examination, and a moderate level of medical decision-making.

(Patient’s health plan permits the reporting of CPT E/M consultation codes.)

Question

Assign code(s) for physician services.

ICD-10-CM: FILL IN WITH CODE, FILL IN WITH CODE

,

CPT: FILL IN WITH CODE

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