EM Coding Alert

Question: After a level-three evaluation and management (E/M) service for an established patient, the surgeon diagnoses carpal tunnel syndrome and performs a therapeutic injection. How should I report this encounter?

Iowa Subscriber

Answer: For this encounter, you should report the injection, an E/M, and a drug supply code (more on that later). So, on your claim, report:

• 20526 (Injection, therapeutic (eg, local anesthetic, corticosteroid), carpal tunnel) for the injection;
• Modifier LT (Left side) or RT (Right side) appended to 20526 to indicate laterality;
• 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.) 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 99212 to indicate that a significant, separately identifiable E/M service preceded the injection; and
• One of the following diagnosis codes appended to 20526 and 99212, depending on encounter specifics:

o G56.00 (Carpal tunnel syndrome, unspecified upper limb);

o G56.01 (Carpal tunnel syndrome, right upper limb); or

o G56.02 (Carpal tunnel syndrome, left upper limb).

Another thing: Your encounter description doesn’t indicate what drug and amount your provider used during the injection. Go back and check the notes, or ask the provider, about the drug supply. Here is a list of the drugs commonly associated with 20526 claims:

• J0665 (Injection, bupivicaine, not otherwise specified, 0.5 mg)
• J0702 (Injection, betamethasone acetate 3 mg and betamethasone sodium phosphate 3 mg)
• J1020 (Injection, methylprednisolone acetate, 20 mg)
• J1030 (Injection, methylprednisolone acetate, 40 mg)
• J1040 (Injection, methylprednisolone acetate, 80 mg)
• J1094 (Injection, dexamethasone acetate, 1 mg)
• J1100 (Injection, dexamethasone sodium phosphate, 1 mg)
• J1700 (Injection, hydrocortisone acetate, up to 25 mg)
• J1710 (Injection, hydrocortisone sodium phosphate, up to 50 mg)
• J1720 (Injection, hydrocortisone sodium succinate, up to 100 mg)
• J2920 (Injection, methylprednisolone sodium succinate, up to 40 mg)
• J2930 (Injection, methylprednisolone sodium succinate, up to 125 mg)
• J3301 (Injection, triamcinolone acetonide, not otherwise specified, 10 mg)
• J3302 (Injection, triamcinolone diacetate, per 5 mg)
• J3303 (Injection, triamcinolone hexacetonide, per 5 mg).