Neurology & Pain Management Coding Alert

Question: Our PM specialist performed a level-three evaluation and management (E/M) service for an established patient with an elbow effusion. What is effusion, and how should I choose an ICD-10 code for elbow effusion?

Massachusetts Subscriber

Answer: First, the ICD-10 coding options. For this patient, you should choose one of the following ICD-10 codes to append to 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity …), depending on patient specifics:

• M25.421 — Effusion, right elbow
• M25.422 — Effusion, left elbow
• M25.429 — Effusion, unspecified elbow.

Effusion explanation: According to Codify, effusion of the elbow joint “refers to an increase in the amount of fluid within the joint or in tissues that surround the joint, often the result of injuries, infections, and certain types of arthritis.”

Some of the symptoms of effusion include pain, swelling, warmth, stiffness, and restricted joint movement. Once the provider documents the effusion, treatment might include:

• Prescription of nonsteroidal anti-inflammatory drugs (NSAIDs);
• Alternating application of heat and ice;
• Use of steroids, antirheumatics, or antibiotics; or
• Aspiration of the joint.