EM Coding Alert

Distinguish between new and existing patients to assign the appropriate E/M code.

Injuries to the toe are frequently seen in podiatry. When your podiatrist carries out an X-ray to identify the injury, it’s crucial that you understand how to document the injury, how to choose the appropriate level for the evaluation and management (E/M) office visit, and how to properly document the X-ray procedure(s).

Examine the given situation below and determine how to appropriately select the correct CPT® and ICD-10-CM codes for this claim.

Scenario: An established patient is complaining of pain in their right fifth toe. The patient recently dropped a can of paint on their foot while cleaning their garage. The patient has mild edema and swelling in the toe. They have been wearing a brace for the pain. The patient has additional complaints of pain from ingrown toenails in both great toes. The podiatrist performed three X-ray views of the patient’s foot to make sure there was no fracture present. The podiatrist saw no fracture, so they applied buddy splinting to the fourth toe to help with the pain. The podiatrist examined both of the patient’s great toes and noted that they did have ingrown toenails in both, so they asked the patient to continue vinegar soaks and applying previously prescribed creams for the ingrown nails. The podiatrist spent 26 minutes on the date of the encounter with the patient. The podiatrist also performed a medically appropriate history at the time of the visit.

Step 1: Choose Appropriate E/M Code

Office visit: For the office/outpatient E/M, you will bill 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 total time on the date of the encounter for code selection, 20 minutes must be met or exceeded).

Why? The patient has two self-limiting or minor problems: the toe swelling with edema and ingrown toenails. This would equate to a low level of medical decision making (MDM) for the number and complexity of problems. The recommended treatment plan would also present a low risk of morbidity to the patient, as the plans of care for both patient’s conditions are not completely without risk. As the testing is being reported separately, no data element will be used in the MDM calculation. Consequently, as two of the three MDM elements have been fulfilled at a low level, this would give a low overall MDM level for the encounter.

Step 2: Choose Appropriate CPT^® Code

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

You would report 73630 because the podiatrist documented that they took three X-ray images of the patient’s foot. According to 73630’s code descriptor, to report this code, the physician must have taken a minimum of three X-ray images.

A Note on X-rays

In a case where your podiatrist is curious about whether a patient’s issue is due to injury or disease or whether it is congenital, they may ask for a set of comparison X-rays. In these situations, the podiatrist will order films of both feet to compare the painful foot to the healthy foot.

The majority of insurance providers typically do not cover comparison X-rays when they are conducted on adult patients. Some insurers will cover comparisons in children to evaluate for growth plate injuries, but that doesn’t apply to adults and it wouldn’t apply in situations such as this encounter.

Step 3: Look at ICD-10-CM Options

Once they finished taking the X-rays, the podiatrist found that the patient had not fractured their foot. The podiatrist diagnosed the patient with localized edema, which would be coded to R60.0 (Localized edema). The podiatrist also diagnosed the patient with ingrown nails, which codes to L60.0 (Ingrowing nail).

Don’t miss: If the patient did have a fracture, you would need to document the date of injury and if it was work related or due to an accident, says Jeri L Jordan, CPC, billing manager at Hampton Roads Foot and Ankle in Williamsburg, Virginia.

Edema defined: When a patient has an edema, they have an excess of fluid in their subcutaneous tissues. The edema can be localized or systemic.

Step 4: Add Your Codes to the Claim

For this particular encounter, you should report the following codes:

• 73630-RT
• 99213-25 (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)
• R60.0
• L60.0

Here’s why modifier 25 was added to the office visit: The E/M service (evaluation of the toe pain and ingrown toenails, including the history taking and decision making) involves two separate and significant services: the evaluation and management of the ingrown toenail and the evaluation and management of the injury, which are significant and separate services from the X-ray procedure. Because of this, you would append modifier 25 to the E/M service to indicate to the payer that the procedures and the E/M were distinct and occurred on the same day.