Orthopedic Coding Alert

Question: Encounter notes indicate that the surgeon performed a 41-minute office evaluation and management (E/M) service for a new patient with left knee pain. The orthopedist orders “x-ray, knee, arthrography w/supervision/interp.” Final diagnosis was staphylococcal arthritis of the right knee. How should I code this encounter, and what is an arthrography?

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Answer: On the claim, you should report:

• 73580 (Radiologic examination, knee, arthrography, radiological supervision and interpretation) for the X-ray
• Modifier LT (Left side) appended to 73580 to indicate laterality
• 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.) for the E/M
• M00.061 (Staphylococcal arthritis, right knee) appended to 73580 and 99203 to represent the patient’s arthritis

More on arthrography: Arthrography is an imaging procedure in which the provider injects contrast dye into a joint (such as the knee) to better visualize the joint’s structures. Arthrographies are a great diagnostic tool for conditions such as joint injuries, arthritis, and tears in ligaments or cartilage. The contrast dye helps highlight the joint structures on the X-ray.