Anesthesia Coding Alert

Question: A new patient arrived with complaints of shoulder weakness and pain. My pain management specialist took a detailed history, performed a detailed exam, and did a diagnostic suprascapular nerve block to check for pain-causing nerve entrapment. Which codes are appropriate for this encounter? Florida Subscriber Answer: You should report the nerve block as 64418 (Injection, anesthetic agent; suprascapular nerve). The office visit probably involved low-complexity medical decision making (MDM). Provided you have separate documentation that supports a level-three new-patient exam, report 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a detailed history; a detailed examination; medical decision making of low complexity ... Usually, the presenting problem[s] are of moderate severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family) with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on [...]