EM Coding Alert

Question: A patient reports to the PM practitioner complaining of pain in their upper right arm. They describe the pain as a 7 on a scale of 10, and that it radiates down their right arm. There is also swelling in the injured area. The physician uses palpation to check for tight bands of muscle; they finally locate a spot in the patient’s arm that causes a brief muscle contraction when it is palpated. The physician then orders a magnetic resonance imaging (MRI) of the arm to rule out any other damage, and diagnoses the patient with causalgia of the upper right arm.

How should I code this encounter?

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Answer: For this patient, you should report:

• 73218 (Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; without contrast material(s)) for the MRI
• Modifier RT (Right side) appended to 73218 to indicate laterality
• The appropriate office/outpatient evaluation and management (E/M) code from the 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 total time on the date of the encounter for code selection, 15 minutes must be met or exceeded.) through 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 total time on the date of the encounter for code selection, 40 minutes must be met or exceeded.) code set
• 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 the E/M code to show that the E/M and the MRI were significant, separately identifiable services
• G56.41 (Causalgia of right upper limb) appended to 73218 and the E/M code to represent the patient’s causalgia.