1. Procedure and CPT® Code Selection:
The urinalysis performed was non-automated and without microscopy.
CPT® Code 81002 is appropriate for a non-automated urinalysis without microscopy. This code accurately reflects the test performed in the office.
2. Diagnosis and ICD-10-CM Code Selection:
ICD-10-CM Code R30.0 is used for dysuria, which was one of the patient's presenting symptoms.
ICD-10-CM Code R10.30 is used for lower abdominal pain, another presenting symptom.
Since the urinalysis ruled out a urinary tract infection, N39.0 (UTI) is not appropriate as a final diagnosis.
3. Rationale for Excluding Other Options:
Code 81000 (in options A and B) is for a urinalysis with microscopy, which was not performed here.
N39.0 is used when a UTI is confirmed, which is incorrect for this case since the urinalysis was negative, ruling out UTI.
4. AAPC and CPT® Coding Guidelines:
AAPC guidelines recommend coding based on the symptoms when a specific diagnosis (such as UTI) is ruled out. Therefore, R30.0 and R10.30 are appropriate symptom codes for this encounter.
Thus, the correct answer is C. 81002, R30.0, R10.30.
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