Internal Medicine Coding Alert

Learn the right way - and the wrong way - to code joint injections

Coding sprains and joint injections is a daunting task when your internist doesn't bill for sports injury treatments on a daily basis. Here's the expert advice you need to code sprains and joint injections without second-guessing yourself.

Charge for the Supplies, Too

Your internist might not treat fractures, but he may treat sprains and strains. When your internist treats a sprain, you can get reimbursement for almost every detail of the physician's services.

Case study #1: Your internist treats a new patient's sprained thumb that he injured while playing "touch football." The physician asks about the patient's medical history, examines the thumb and wraps it with an ACE bandage to immobilize it.

How to code: Report 29280 (Strapping; hand or finger) with 842.12 (Sprains and strains of wrist and hand; metacarpophalangeal [joint]) for your internist's treatment of the sprained thumb. Some payers don't consider applying ACE bandages as strapping, so ask the payer about its guidelines, says Jean Acevedo, LHRM, CPC, CHC, senior consultant with Acevedo Consulting Inc. in Delray Beach, Fla.

Remember to bill for the bandage the internist used to wrap the thumb, says Catherine Brink, CMM, CPC, president of HealthCare Resource Management Inc. in Spring Lake, N.J. Use codes A6448 (Light compression bandage, elastic, knitted/woven, width less than 3 in., per yard) and A6450 (... width greater than or equal to 5 in., per yard) to charge for the wrap.

Another tip: If the internist performs an x-ray on the patient's thumb, make sure you report the x-ray code (73120-73140). You can also report an E/M code (99201-99205) for the office visit with the new patient and attach modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code, Brink says. Modifier 25 will signal your payer that the E/M was separate from the sprain treatment and could prevent a denial.

Watch for: When the same patient returns to see your internist because his thumb is tingling and numb, be careful which diagnosis code you choose. You should list the late-effects diagnosis code first, because the numbness is what the internist is assessing during this second visit, Acevedo says. Use ICD-9 code 905.7 (Late effect of sprain and strain without mention of tendon injury) and list 842.12 second, she says.

Get a Clear Picture of Joint Injections

Another sports injury treatment that your internist might perform is a joint injection. Tip: Make sure that your joint injection code correctly identifies the joint as small, medium or large, Brink says. For example, the arthrocentesis codes (20600, 20605 and 20610) identify finger and toe joints as small joints, while shoulder, hip and even knee joints are large joints, she says.

Plus: Remember to report the "J" code to charge for the drug and remind your internist to specify which drug - and the exact dosage - he injected. If the physician doesn't include these details in the medical notes and you guess which drug and dosage to code, you could lose your reimbursement in an audit, Acevedo warns. For example: Your internist's notes say, "Gave patient Depo-Medrol injection" and doesn't document a specific dosage. If you reported J1040 (Injection, methylprednisolone acetate, 80 mg), you wouldn't have any documentation to support the claim in an audit.

Case study #2: Your internist treats a new patient for her elbow pain. The internist drains fluid from the patient's elbow, injects 20 mg of Depo-Medrol and schedules her for a follow-up visit.

Report 20605 (Arthrocentesis, aspiration and/or injection; intermediate joint or bursa [e.g., temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa]) for the draining and injection. You can use code J1020 (Injection, methylprednisolone acetate, 20 mg) for the injectable. You can use 719.42 (Pain in joint; elbow) to code the patient's symptom, because the physician hasn't offered a diagnosis.

You may list the appropriate E/M code (99201-99205) with modifier 25 attached, if your internist recorded the patient's medical history and otherwise met the requirements to charge a separate E/M, Brink says.

Be careful when you code an E/M with the follow-up visit, especially when the patient has no new symptoms, experts say. "Don't automatically bill an E/M with a second office visit," Brink says. When the patient comes for a follow-up visit and tells the internist that her elbow isn't better, but she doesn't have any new symptoms, the situation probably won't qualify for a separate E/M - even if the internist administers a second injection, she says.

If you're coding a joint injection in a finger, use the "F" modifiers in your HCPCS book to specify which finger, Acevedo says. While using the modifier for a joint injection in just one finger is primarily for informational purposes, you need the modifiers the most for injections in multiple fingers, she explains.

For example: Your internist performs two joint injections in a patient's right thumb and right ring finger. He drains fluid from the patient's joints and injects 20 mg of Depo-Medrol in each finger. You should report 20600 (Arthrocentesis, aspiration and/or injection; small joint or bursa [e.g., fingers, toes]) with modifier F5 (Right hand, thumb) and append the second 20600 with  modifier 59 (Distinct procedural service) and modifier F8 (Right hand, fourth digit). List J1020-F5 and J1020-F8 for the Depo-Medrol injections in each finger.