Orthopedic Coding Alert

Question: When we see a patient for a new pain-related problem, I usually report the E/M code with a pain diagnosis, such as 719.43 (Pain in joint, forearm). When the patient returns for subsequent visits, we usually have a more definitive diagnosis, such as 814.01 (Fracture of carpal bone[s], closed; navicular [scaphoid] of wrist), and I report that instead. My orthopedist thinks we should hold the first E/M visit until we have the definitive diagnosis, so that all of the E/M visits have the same ICD-9 code (814.01). Is she correct?

Colorado Subscriber
  Answer: The ICD-9 guidelines state, "If symptoms are present but a definitive diagnosis has not yet been determined, code the symptoms." Your question indicates that your orthopedist did not diagnose the patient's wrist sprain until after the first visit (most likely following x-ray or other test results). If this is the case, you should report the appropriate E/M code (99211-99215) for the initial E/M encounter and link it to the wrist pain diagnosis code 719.43.

After the orthopedist determines a diagnosis, you should report only the new diagnosis code (814.01), and you should no longer use the wrist pain ICD-9 codes.