Question: A 20-year-old patient reported to the ED with right knee and thigh pain. During an E/M service, the physician examined the patient, and recommended ice and nonsteroidal anti-inflammatory drugs (NSAIDs) for the patient’s thigh. For the knee injury, notes indicate that the E/M led to an aspiration without ultrasound to relieve the patient’s pain. How should I code this encounter? Codify Subscriber Answer: You’ll likely be able to report an E/M and a procedure code, but you’ll probably need some help from a pair of modifiers. Why? The best way to prove these are separate services is by documenting the patient’s pair of injuries via ICD-10. As for the modifiers, you’ll need them to set the E/M apart from the aspiration and (possibly) to indicate laterality for the injection.
On the claim, you’ll report: