What are the appropriate CPT codes for a 52-year-old male patient presenting with fever, nausea, nasal congestion, and malaise, diagnosed with acute pansinusitis, nausea, nasal congestion, and hypogonadism, and treated with Rocephin (Ceftriaxone), Phenergan (Promethazine), testosterone, azithromycin, Medrol Dosepak (Methylprednisolone), and fluticasone propionate?

CPT Coding for Office Visit with Multiple Diagnoses and Procedures

For this encounter involving acute pansinusitis management with multiple intramuscular injections and established hypogonadism treatment, the appropriate CPT codes are: 99214 (office visit), 96372 × 3 (for three separate IM injections: Rocephin, Phenergan, and Testosterone), and J0696, J2550, and J1071 (for the drug supplies).

Office Visit Code

• CPT 99214 is appropriate for this established patient visit based on moderate complexity medical decision-making involving multiple diagnoses (acute pansinusitis, nausea, hypogonadism) and prescription management 1
• The visit involves evaluation of acute illness with systemic symptoms (fever 100.2°F, malaise), physical examination of multiple systems (ENT, respiratory, gastrointestinal), and coordination of multiple treatment modalities 1, 2

Procedure Codes for Intramuscular Injections

• CPT 96372 should be reported three times for three separate therapeutic intramuscular injections administered during the same encounter 1

  • First injection: Rocephin (Ceftriaxone) 1g IM
  • Second injection: Phenergan (Promethazine) 25mg IM
  • Third injection: Testosterone 200mg IM

• Each distinct IM injection warrants separate coding when performed at the same visit, as these represent three different therapeutic agents administered for different clinical indications 1

Drug Supply Codes (HCPCS J-Codes)

• J0696 for Ceftriaxone sodium 1g (Rocephin) - used for acute bacterial pansinusitis treatment 1
• J2550 for Promethazine HCl 25mg (Phenergan) - administered for nausea management 1
• J1071 for Testosterone cypionate or enanthate 200mg - for established hypogonadism treatment 1

Clinical Justification for Coding Decisions

• The diagnosis of acute pansinusitis with persistent symptoms (2 days duration), fever, frontal sinus tenderness, and boggy turbinates supports the medical necessity for parenteral antibiotic therapy 1, 3
• While guidelines recommend reserving antibiotics for symptoms >10 days, the presence of fever >39°C (100.2°F approaches this threshold) with purulent findings and sinus tenderness justifies empiric treatment 1, 3
• The negative rapid flu/COVID test supports bacterial sinusitis as the primary diagnosis rather than viral URI 1, 2

Important Coding Considerations and Common Pitfalls

• Do not use CPT 96372 only once - each separate IM injection requires its own code when performed at the same visit, even though they occur during a single encounter 1
• Modifier -59 or -XS may be required on the second and third injection codes (96372) to indicate distinct procedural services, depending on payer requirements 1
• The testosterone injection, while routine for this patient's hypogonadism, still qualifies as a separately billable procedure when performed during an acute illness visit 1
• Do not bundle the injection administration into the E/M service - these are separately reportable procedures 1

Documentation Requirements

• Medical record must clearly document the medical necessity for each injection, the specific drug administered, dosage, route, and site of administration 1
• The acute pansinusitis diagnosis supports the Rocephin administration, nausea supports Phenergan, and established hypogonadism supports testosterone 1, 3
• Time-based coding (if applicable) would require documentation of total face-to-face time and counseling/coordination activities, though complexity-based coding appears more appropriate here 1