EM Coding Alert

Hint: Remember the anatomical modifier.

As a coder, you know that E/M service codes are only one part of the coding puzzle. Consider this podiatry scenario as a case study, and try your hand at figuring out the correct E/M code, as well as other applicable codes for this encounter.

See which E/M, X-ray CPT^®, and ICD-10-CM codes, respectively, are the best choices for this situation.

Scenario: An established patient is experiencing right dorsal foot pain because she dropped a cutting board on the top of her foot while cooking dinner. This is the same foot the patient broke two years ago, and she is concerned that she has fractured another bone. The patient presents with minimal discomfort with palpitation of the fifth metatarsophalangeal (MTPJ) joint and forefoot area. The patient has mild edema and no ecchymosis. The podiatrist performs a three-view X-ray, AP, lateral, and MO, to rule out fractures.

After the exam, the podiatrist diagnoses the patient with metatarsalgia, pain in the ankle and joints of the foot, and localized edema. The X-rays show that the patient’s prior fifth metatarsal fracture from two years ago is well-healed with no signs of new breaks. The podiatrist discusses utilizing a combination of stretching exercises, anti-inflammatory medications, and reduced activity until her pain subsides. She will also modify her workout program pending the pain level. The podiatrist documents that he spent 22 minutes with the patient. He performed a medically appropriate history and exam during this encounter.

Step 1: Spotlight Correct CPT^® Codes

E/M: For the E/M code for this office visit, you should report 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter.)

Although there are multiple other E/M codes to choose from, 99213 is the correct option in this case because according to the medical documentation, the podiatrist spent 22 minutes with the patient. He also performed a medical appropriate history and exam. This information all fits 99213’s code descriptor.

Established vs. new patient: You should note that in this case, the patient is established, which is an important detail you must consider when reporting E/M codes.

For an established patient, you should look to codes 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 10-19 minutes of total time is spent on the date of the encounter.)-99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.)

On the other hand, for a new patient, you would have looked at codes 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter.)-99205 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 60-74 minutes of total time is spent on the date of the encounter.)

Don’t miss: In this case, the podiatrist used the total time spent with the patient on that date of service to level the E/M service.

X-ray: For the X-ray service, you should report 73630 (Radiologic examination, foot; complete, minimum of 3 views)-RT (Right side).

You would report 73630 because the podiatrist documented that he took three X-ray images of the patient’s foot. He also documented what type of views he took: AP (anteroposterior), lateral, M.O. (medial oblique). According to 73630’s code descriptor, to report this code, the physician must have taken a minimum of three X-ray images. If, for example, the podiatrist had only taken two X-ray images of the patient’s foot, then you should have reported 73620 (Radiologic examination, foot; 2 views) instead.

Step 2: Look to These ICD-10-CM Codes

Upon completing the X-rays, the podiatrist discovered that the patient had not fractured her foot.

The podiatrist diagnosed the patient with localized edema and metatarsalgia in her right foot, so, in this case, you will report R60.0 (Localized edema) and M77.41 (Metatarsalgia, right foot) as the diagnosis codes on your claim.

Define Edema: An edema is “the presence of abnormally large amounts of fluid in the intercellular tissue spaces of the body, usually referring to subcutaneous tissues,” according to Dorland’s Illustrated Medical Dictionary. “It may be localized (such as from venous obstruction, lymphatic obstruction, or increased vascular permeability) or systemic (such as from heart failure or renal disease).”

Step 3: Consider Your Coding Complete

In summary, for this encounter, you should report the following codes:

• 73630-RT
• 99213
• R60.0
• M77.41