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?

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 the same day of the procedure or other service). You need the modifier to indicate the E/M is significant and separately identifiable from the minor E/M included in 64418.

Watch out: If your provider's documentation, however, did not indicate a separately identifiable and significant E/M service beyond the pre- and post-injection work included in the injection procedure, it would not be appropriate to bill for the initial E/M service.