ED Coding and Reimbursement Alert

Question: A patient reports to the ED complaining of left shoulder pain. The provider performs an evaluation and management (E/M) service that involves a detailed history, examination and moderate-complexity medical decision making (MDM). Based on the E/M, the provider orders a computed tomography (CT) on the patient’s shoulder with computed tomography (CT). Final diagnosis was solitary bone cyst, left shoulder. How should I report this encounter?

Maine Subscriber

Answer: On the claim, you’ll report:

• 73201 (Computed tomography, upper extremity; with contrast material(s)) for the CT scan
• 99284 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity.) for the E/M
• Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) appended to 99284 to show that a significant, separately identifiable E/M preceded the CT scan.
• M85.412 (Solitary bone cyst, left shoulder) appended to 73201 and 99284 to represent the patient’s injury

FYI: For coders who are unfamiliar with this condition, “a solitary bone cyst of the … shoulder, also known as a simple bone cyst, is a benign, empty or fluid filled cavity in bone that can weaken it,” according to Codify by AAPC.