Orthopedic Coding Alert

Question: A new patient visited the office to have a ganglion cyst of the ankle drained. During the visit, the practitioner performed a detailed exam and history in which the patient explained the cyst slowly started appearing after they had open reduction and internal fixation (ORIF) surgery two years ago to repair a broken fibula. The physician fully aspirated the cyst on the patient’s right ankle while in the office. How should I report this visit?

AAPC Forum Participant

Answer: You’ll need the following codes on your claim:

• 20612 (Aspiration and/or injection of ganglion cyst(s) any location) for the cyst aspiration procedure
• 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 total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.) for the office visit
• Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) appended to 99203 to show that the E/M was significant and separate from the cyst aspiration procedure
• M67.471 (Ganglion, right ankle and foot)

Make note: If the visit required you to aspirate multiple ganglion cysts, you would add modifier 59 (Distinct procedural service) to each instance of 20612 instead of using 20612 x 2.

Lindsey Bush, BA, MA, CPC, Production Editor, AAPC