Orthopedic Coding Alert

Question: Notes indicate that the surgeon performed a level-four office evaluation and management (E/M) service for a new patient with pain in their left ankle and toes. After a magnetic resonance imaging (MRI) study of the ankle and foot with contrast material, the surgeon diagnoses ‘loose body, L ankle/great toe.’ How should I code this encounter?

Louisiana Subscriber

Answer: On the claim, report:

• 73722 (Magnetic resonance (eg, proton) imaging, any joint of lower extremity; with contrast material(s))
• Modifier LT (Left side) appended to 73722 to indicate laterality
• 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is spent on the date of the encounter.) for the E/M
• M24.072 (Loose body in left ankle) appended to 73722 and 99204 to represent the patient’s ankle injury
• M25.075 (Loose body in left toe joint(s)) appended to 73722 and 99204 to represent the patient’s foot injury.