Rotational and angular variations of the lower extremities in children are common conditions seen in primary care. These visits are often due to parental concerns about the appearance of their child's lower extremities.
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A 56-year-old patient with a history of hypertension and chronic obstructive pulmonary disease was admitted from the emergency department with a 1-week history of nausea, vomiting, and diarrhea. On examination, the patient was afebrile, blood pressure was 98/65 mm Hg, heart rate was 118 beats per minute, and respiratory rate was 28 breaths per minute. Laboratory results were as follows:
- Arterial blood gas: pH = 7.52, Paco2 = 45 mm Hg (5.99 kPa), Pao2 = 82 mm Hg (10.91 kPa) on room air
- Serum: sodium = 145 mEq/L (145 mmol/L), potassium = 3.2 mEq/L, chloride = 98 mEq/L (98 mmol/L), HCO3 = 38 mEq/L (38 mmol/L), urea nitrogen = 15 mg/dL (5.35 mmol/L), creatinine = 1.2 mg/dL (106.08 μmol/L), glucose = 185 mg/dL (10.27 mmol/L)
- Spot urine chloride less than 10 mEq/L (10 mmol/L)
Pricing for MI-Heart Ceramides testing (Current Procedural Terminology [CPT] code 0119U) varies, and insurance does not generally cover this test. The cost for individual testing without insurance is about $180.
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Comparison of the pH and Paco2 indicates that the primary process is metabolic alkalosis. Figure 4 summarizes the analysis for this case.29,30
ACCURACY
The MI-Heart Ceramides test results are used to stratify a patient's absolute 5-year risk for adverse cardiovascular events on a 12-point scale.Scoring is determined by stratification of results into quartiles for three individual blood ceramide levels: Cer(16:0)55, Cer(18:0), and Cer(24:1), and three individual blood ceramide ratios: Cer(16:0)/Cer(24:0), Cer(18:0)/Cer(24:0), and Cer(24:1)/Cer(24:0). Zero points are given for values in the first or second quartile, 1 point for values in the third quartile, and 2 points for values in the fourth quartile, to make a summative score of up to 12 points.
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Lorem Ipsum is simply dummy text of the printing and typesetting industry. Lorem Ipsum has been the industry's standard dummy text ever since the 1500s, when an unknown printer took a galley of type and scrambled it to make a type specimen book.
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Figure 1 Text about the Figure
It is important to note that critically ill patients often present with, or develop, mixed acid-base disturbances, particularly when serum HCO3 and Paco2 levels deviate in opposite directions from their normal values
Table 1 A table for viewing
Normal Values for Acid-Base Analysis |
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| Measurement | Normal Value | Reference Range |
| pH | 7.4 | 7.38 - 7.42 |
BUN = serum urea nitrogen; Cl = chloride; HCO3 = bicarbonate; K = potassium; Na = sodium.
Table 2 Inside Background Container
| A table inside background container | |
| column 1 | column 2 |
| value 1 | value 2 |
HCO3 = bicarbonate.
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Table 3 Inline Image Testing
| Column 1 | Column 2 |
| Value 1 | Value 2 |
SORT: KEY RECOMMENDATIONS FOR PRACTICE
Excision of Skin Lesions
I have been told I must hold code selection and billing for excising skin lesions until we receive the pathology report to confirm whether an excised lesion was benign or malignant. Is that correct?
Yes, to a point. Current CPT guidance is to delay coding and billing until the pathology has been confirmed, unless the excised lesion is clearly benign or clearly malignant. This is true regardless of the method of excision. If you are confident the lesion is clearly benign or clearly malignant, you may code it as such up front and then file a revised claim if the pathology report says otherwise.
For ICD-10 coding, when you're unsure whether the lesion is benign or malignant, either hold the claim until the pathology report is available or submit an unspecified diagnosis code. Do not report codes for neoplasms of uncertain behavior unless the pathologist's report reflects that (e.g., a lesion that may be transitioning to malignancy).
Q & A
MEDICARE COVERAGE OF IMMUNIZATIONS MEDICARE COVERAGE OF IMMUNIZATIONS
What immunizations are covered under Medicare Part B? How do I:
- Get reimbursed?
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Medicare Part B covers routine immunizations against COVID-19, pneumococcal illness, hepatitis B, and influenza. (Other routine recommended immunizations, such as RSV and zoster, are covered under Part D.) When reporting routine immunization, use the appropriate CPT code for the vaccine product and an appropriate immunization administration code:
- 90480 for administration of COVID-19 vaccine,
- G0008 for administration of influenza virus vaccine,
- G0009 for administration of pneumococcal vaccine,
- G0010 for administration of hepatitis B vaccine.
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Link diagnosis code Z23 (encounter for immunization) to the vaccine product and administration codes. You may report other ICD-10 codes secondary to Z23 to indicate immunization in patients who have an underlying condition or other risk factor such as diabetes mellitus or end-stage renal failure.
Medicare Part B also covers non-routine vaccines, antitoxins, antivenin sera, and immune globulins administered to treat injury or direct exposure to a disease or condition (e.g., tetanus antitoxin or vaccine booster). Link a diagnosis code for the injury or other condition (e.g., S91.331A for puncture wound without foreign body, right foot, initial encounter) to the product and administration codes (e.g., 90471, immunization administration by injection).
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E/M Complexity Code g2211 Frequency
Is there a frequency limitation for the G2211 "visit complexity" add-on code?
No, the Centers for Medicare & Medicaid Services (CMS) did not set a frequency limitation. CMS noted in the 2024 Medicare Physician Fee Schedule final rule that it expects primary care specialties to have higher G2211 utilization than others. Like any office visit, the visits you report in conjunction with G2211 must be clinically indicated and must be provided either in the context of a longitudinal care relationship or as part of ongoing care related to a patient's single, serious condition or complex condition. If office visits take place at a frequency or for a purpose beyond what is reasonable and necessary for the patient's health care needs, Medicare may deny the claim, initially or retroactively after payment. For more information, see “G2211 Update and Infographic: When to Use the Visit Complexity Add-On Code” in the January/February 2025 issue of FPM.
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