Orthopedic Coding Alert

Question: Encounter notes indicate that the provider performed a level-four evaluation and management (E/M) service for a new patient, and then performed a tendon sheath injection. How should I report this encounter?

Tennessee Subscriber

Answer: You'll most likely report 20550 (Injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar "fascia")) for the injection.

For the E/M service, you'll report 99213 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a detailed history; a detailed examination; medical decision making of low complexity ...) with 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 show that the E/M led to the sheath injection.