Neurology & Pain Management Coding Alert

Question: The physician saw a new patient with a complaint of right-sided extremity pain; more specifically, the patient complained of pain in his shoulder, emanating to his elbow, wrist, and the joints of his hand. During an evaluation and management (E/M) service that included an expanded problem-focused history and detailed examination, the physician prescribed rest and ibuprofenfor the patient, and told him to return in six weeks if the symptoms persisted. How should I code this encounter? Is there a single diagnosis code for all of thepatient's symptoms?

Montana Subscriber

Answer: There isn't a single diagnosis code for this encounter, but there is a single CPT^® code: 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: an expanded problem focused history; an expanded problemfocused examination; straightforward medical decision making ...).

As for the diagnosis codes you'll append to 99202, your best bet is to list the following in descending order:

• M25.511 (Pain in right shoulder) to represent the patient's shoulder pain.
• M25.521 (Pain in right elbow) to represent the patient's elbow pain.
• M25.531 (Pain in right wrist) to represent the patient's wrist pain.
• M25.541 (Pain in joints of right hand) to represent the patient's hand pain.