Orthopedic Coding Alert

Question: An established patient with a history of wrist issues reports to the orthopedist with a “lump” on her right wrist which, after a level-two evaluation and management (E/M) service, the orthopedist removes. Final notes indicate she made an incision near the wrist joint, isolated the wound (ganglion), and removed it using a scalpel. I’m sure this is a ganglion cyst removal, but is it primary or secondary?

Indiana Subscriber

Answer: The notes could lead you to make an educated guess, but you’re better off asking the provider. We can, however, narrow down your procedure code choices and get the proper E/M code, modifier, and ICD-10 code for the encounter.

For the ganglion removal, report 25111 (Excision of ganglion, wrist (dorsal or volar); primary) or 25112 (…recurrent). Since there is no way to tell for certain if a ganglion is primary or recurrent by your description, you’ll have to get more information before making the final call. If the provider requires laterality modifiers, append modifier RT (Right Side) to the removal code.

You’ll report the E/M service with 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making…). Append modifier 57 (Decision for surgery) appended to 99212 regardless of the excision code, as both 25111 and 25112 have global periods of 90 days.

Also, append M67.431 (Ganglion, right wrist) to the ganglion removal code and 99212 to represent the patient’s condition.

Given that the patient is established, has a history of wrist issues, and received a low-level E/M before the excision, you might believe that this is a recurrent ganglion. It is dangerous, however, to make that call on your own. Check with the performing provider, and make a note in the record that the patient has a history of wrist ganglion — whether this particular encounter was for a primary or recurrent injury, the patient now has a history of wrist ganglion. That way, it won’t be so difficult if the patient returns for another treatment of the same injury.