Orthopedic Coding Alert

To get a more complete picture of how a knee arthroscopy scenario might play out, take a look at this example from Jessyka Burke, BHSA, CPC, COSC, CASCC, coding specialist at Cascade Orthopaedics in Auburn Washington.

The three encounters take us from initial visit with the surgeon to knee arthroscopy:

Encounter 1: Pt presents with left knee pain and locking which became unbearable 2 weeks prior to initial appointment with orthopedic surgeon. Discussion was had as to events or injuries that occurred prior to the unbearable pain. Patient was seen in the ER 2 months prior to seeing orthopedic surgeon, and x-rays and notes were reviewed and documented. After this and physical exam, which showed positive McMurray’s, small to moderate effusion, medial joint line pain, no lateral joint line pain, decision made to proceed with MRI of left knee to rule out medial meniscal injury.

• CPT^® coding: 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/ or examination and moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is spent on the date of the encounter.), 73721
• ICD-10 coding: M25.562 (Pain in left knee), M25.462 (Effusion, left knee)

Encounter 2: Pt returned after MRI was done for review and decision for treatment. After review of MRI and independent review showing high grade radial and horizontal tearing of posterior root and horn of the medial meniscus and small effusion, decision was made after decision with patient and family to proceed with Left knee arthroscopic medial meniscectomy. Surgery will be next day.

• CPT^® coding: 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter.)
• ICD-10 coding: S83.242A (Other tear of medial meniscus, current injury, left knee, initial encounter)
• Modifier: 57 (Decision for surgery)

Encounter 3: Surgery performed was Left Knee arthroscopic partial medial meniscectomy and Diagnosis post operative is left knee medial meniscus tear.

• CPT® coding: 29881 (Arthroscopy, knee, surgical; with meniscectomy (medial OR lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed)
• Modifier: LT (Left side)
• ICD-10 coding: S83.242A.