Internal Medicine Coding Alert

Question: An established patient with carpal tunnel syndrome (CTS) in her right wrist reports to the intern-ist; she says even though she has kept the wrist in a short splint and attended physical therapy, it still "hurts bad" -- specifically that her hand is tingling, her wrist hurts, and she has trouble using her fingers. After performing an expanded problem-focused exam, the internist decides to perform a carpal tunnel injection (CTI). The internist injects 40 mg of Depo-Medrol, puts the wrist back in the splint, and sends the patient home. How do I code this encounter? Is there enough evidence for a separate E/M service?

Minnesota Subscriber

Answer: You should go back and check the encounter specifics to be sure, but it sounds like the internist provided a significant and separately identifiable E/M service.

The procedure code for CTI has a global period of zero days. Therefore, you must be sure that the E/M is indeed separate before reporting the service. If the E/M service is inherent to the procedure, you should not report it separately.

Check out this Correct Coding Initiative Version 14.3 explanation: "If a procedure has a global period of 0 or 10 days, it is defined as a minor surgical procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E/M service. However, a significant and separately identifiable E/M service unrelated to the decision to perform the minor surgical procedure is separately reportable," CCI states.

So let's say the pre-CTI service is a separate E/M; you mentioned the expanded problem-focused exam, and the internist's decision to perform the CTI was a straightforward medical decision.

On the claim, report the following:

• 20526 (Injection, therapeutic [e.g., local anesthetic, corticosteroid], carpal tunnel) for the CTI

• 99212 (Office or other outpatient service for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a problem-focused history; a problem-focused examination; straightforward medical decision making) for the E/M

• modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99212 to show that the E/M and injection were separate services

• 354.0 (Carpal tunnel syndrome) appended to 20526 and 99212 to represent the patient's condition

• J1020 (Injection, methylprednisolone acetate, 20 mg) x 2 for the Depo-Medrol supply.