ED Coding and Reimbursement Alert

Question: A 37-year-old librarian reports to the ED reporting pain at the base of her right radial wrist. She says about four days ago when she was stacking books, it started to ache. She had been using Ibuprofen to control the pain, but she says that it became unbearable yesterday; she reports an 8 on a 10-point pain scale. The ED physician exam reveals tenderness over the wrist; the patient exhibits a positive Tinel sign and is positive for carpal tunnel syndrome. During a level-three E/M service, the physician attempts to treat the patient's pain with anti-inflammatories, to no avail. Using a 22-guage needle, the physician performs a single tendon injection at the origin of the extensor tendon. How should I code this scenario?

Tennessee Subscriber

Answer: On the claim, report the following:

20551 (Injection[s]; single tendon origin/insertion) for the injection

99283 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity ...) for the E/M

Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99283  how that the E/M and the injections were separate services

354.0 (Mononeuritis of upper limb and mononeuritis multiplex; carpal tunnel syndrome) appended to 20551 and 99283 to represent the patient's condition.

Documentation alert: Include notes that describe your physician's traditional attempts to treat the patient's carpal tunnel. It will help prove medical necessity for 20551.