Orthopedic Coding Alert

Question: Encounter notes indicate that the provider met with a new patient complaining of elbow pain. The provider performs an office evaluation and management (E/M) service that involves low-level medical decision making (MDM). After the E/M, the provider orders a two-view elbow X-ray to rule out fracture. Final diagnosis is epicondylitis. How should I report this encounter?

Minnesota Subscriber

Answer: You’re going to need a little more information to select the correct diagnosis code, but the CPT^® coding is pretty straightforward.

CPT^® coding: On the claim, report 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/ or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter.) for the E/M and 73070 (Radiologic examination, elbow; 2 views) for the X-ray. Also, go back and check the notes to see which elbow the provider treated. Then, append either modifier LT (Left side) or RT (Right side) to 73030 to indicate laterality — if there is any indication of laterality in the notes.

ICD-10 coding: You have two choices here: M77.0- (Medial epicondylitis) or M77.1- (Lateral epicondylitis). Medial epicondylitis, also known as golfer’s elbow, is painful inflammation of the tendons that join the forearm muscles on the inner side of the elbow. Lateral epicondylitis, also known as tennis elbow, is painful inflammation of the tendons that join the forearm muscles on the outside of the elbow. Both injuries often occur due to overuse or repeated injury.

Do this: Go back and check if the notes indicate that the physician treated the tendons on the inner or outer side of the elbow. Also, check which elbow the provider treated — if there is any indication of laterality in the notes. Then, chose one of the following ICD-10 codes to append to 99213 and 73030:

• M77.00 (Medial epicondylitis, unspecified elbow)
• M77.01 (Medial epicondylitis, right elbow)
• M77.02 (Medial epicondylitis, left elbow)
• M77.10 (Lateral epicondylitis, unspecified elbow)
• M77.11 (Lateral epicondylitis, right elbow)
• M77.12 (Lateral epicondylitis, left elbow).