Orthopedic Coding Alert

Question: After a level-four evaluation and management (E/M) service during which the orthopedist diagnoses torticollis in a new patient, a surgery is scheduled. Notes indicate that the orthopedist performed “open div/sternocleido­mastoid” during the surgical encounter. How should I report these services, and what is torticollis?

Tennessee Subscriber

Answer: There are two procedure codes to choose from, depending on the specifics of the encounter. Select either 21720 (Division of sternocleidomastoid for torticollis, open operation; without cast application) or 21725 (… with cast application) with M43.6 (Torticollis) appended to represent the patient’s torticollis.

Then, you’ll report 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 …) with M43.6 appended for the E/M. Also, append modifier 57 (Decision for surgery) to 99204 to show that the E/M led to surgery. Be sure to identify the elements of an E/M (history, exam, MDM) that is separate from the E/M services inherent in any surgical code. If you cannot positively identify a separate E/M, consult with the performing surgeon before coding 99204.

Modifier reminder: This surgery has a 90-day (major) global period, meaning you should use modifier 57 on the E/M. You would, however, append 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) to the E/M if the resulting surgery has a 0- or 10-day (minor) global period.

Definition: According to ICD-10, torticollis is “a twisting of the neck due to tight neck muscles.” There is also an EXCLUDES1 note under M43.6 that includes these exceptions to the code’s use:

• Congenital (sternomastoid) torticollis;
• Ocular torticollis;
• Psychogenic torticollis;
• Spasmodic torticollis; and
• Torticollis due to birth injury.

Best bet: If there is any evidence of one of the above conditions in the patient, check the EXCLUDES1 note under M43.6 for coding instructions.