Neurology & Pain Management Coding Alert

Question: During the course of a level-four evaluation and management (E/M) service for a new patient, the provider notes “shoulder and hip pain, right-sided. Also knee pain.” How many diagnosis codes do I need for this encounter?

Florida Subscriber

Answer: You’ll need three diagnosis codes to represent all the diagnoses for this 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a comprehensive history; a comprehensive examination; medical decision making of moderate complexity …) claim:

• M25.511 (Pain in right shoulder) for the shoulder pain
• M25.551 (Pain in right hip) for the hip pain
• M25.569 (Pain in unspecified knee) for the knee pain.

This is as far as you can go, in terms of diagnosis specificity, with the notes you described. Since it did not appear that provider specified the knee pain area in the notes, M25.569 is the best option.