Neurology & Pain Management Coding Alert

Question: Encounter notes indicate that the physician performed an office evaluation and management (E/M) service for a patient with Reiter’s disease in the cervical and thoracic vertebrae. The E/M service involved low-level medical decision making (MDM). How should I report this diagnosis, and what is Reiter’s disease?

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Answer: For the E/M, you’re going to have to go back and check if the patient is new or established. Then, choose either 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.) or 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter.), depending on patient status.

For the diagnosis coding, you should append M02.38 (Reiter’s disease, vertebrae) to 99203 or 99213 to represent the patient’s condition.

You might be tempted to report M02.39 (Reiter’s disease, multiple sites) instead, since the notes list cervical and thoracic Reiter’s disease. But since vertebrae is the most specific spinal designation for Reiter’s disease, two vertebral spots would still warrant a single ICD-10 code.

Reiter’s disease, also known as reactive arthritis, is a type of inflammatory arthritis that typically develops as a reaction to an infection in another part of the body. It is characterized by joint pain, swelling, and stiffness, along with other symptoms such as inflammation of the eyes, urinary tract symptoms, and skin lesions.