Orthopedic Coding Alert

Question: An established patient reports with right knee and thigh pain. During an evaluation and management (E/M) service, the physician examines the patient, and recommends ice and nonsteroidal anti-inflammatory drugs (NSAIDs) for the patient’s thigh. For the knee injury, notes indicate that the E/M led to an aspiration without ultrasound (US) to relieve the patient’s pain. How should I code this encounter?

Florida Subscriber

Answer: You’ll likely be able to report an E/M and a procedure code, but you’ll probably need some help from a pair of modifiers.

Why? The best way to prove these are separate services is by documenting the patient’s pair of injuries via ICD-10. As for the modifiers, you’ll need them to set the E/M apart from the aspiration and (possibly) to indicate laterality for the injection.

CPT^® coding: On the claim, you’ll report:

• 20610 (Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance) for the aspiration.
• Modifier RT (Right side) appended to 20610 to indicate laterality, if the payer requires it.
• An appropriate E/M code from the 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services. …) through 99215 (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 comprehensive history; A comprehensive examination; Medical decision making of high complexity. …) code set for the E/M service.
• 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 the E/M code to show that the E/M and injection were separately identifiable services.