General Surgery Coding Alert

Question: Our surgeon saw a new patient with a chief complaint of left shoulder pain. The surgeon performed an E/M service that lasted 43 minutes and involved low-level medical decision making (MDM). Based on the exam, the surgeon orders a computed tomography (CT) on the patient’s shoulder with contrast. A separate facility performed and interpreted the CT. The final diagnosis for this patient was solitary bone cyst, left shoulder. How should I report this encounter?

Illinois Subscriber

Answer: You can use time to code the surgeon’s evaluation and management (E/M) service in this case. Report 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 30-44 minutes of total time is spent on the date of the encounter.) for the E/M.

The facility performing the CT scan may separately bill that service.

The diagnosis code for this case is M85.412 (Solitary bone cyst, left shoulder). You might see the condition listed in the note as a “simple bone cyst” or just “bone cyst.” The condition is a fluid-filled cavity in a bone (or possibly an empty cavity) that can weaken the bone.