Orthopedic Coding Alert

Question: Our orthopedic surgeon performed a consult for a new patient who has had left shoulder pain for a month. We performed a complete x-ray study of the left shoulder, which we read as normal. The surgeon documented joint inflammation and injected cortisone. How should I code this encounter?

Ohio Subscriber

Answer: Assuming you have adequate documentation, you should report the following codes:

Consult: You should report the new patient consult with the appropriate choice from 99241-99245. These codes apply to both new and established patient consults.

You should append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to indicate that this service is separately identifiable from the injection procedure code.

X-ray: For the complete shoulder x-ray, use 73030 (Radiologic examination, shoulder; complete, minimum of two views). Remember that to report this code, the surgeon must provide and sign a separate written report. If you are reporting only the professional component, you should append modifier 26 (Professional component) to 73030.

Injection: Code 20610 (Arthrocentesis, aspiration and/or injection; major joint or bursa) covers the cortisone injection. Use a corresponding J code to gain reimbursement based on the drug the surgeon injected, such as J3301 (Injection, triamcinolone acetonide, per 10 mg) for Kenalog. Be sure the documentation includes the name, dosage and site for the cortisone the surgeon used.

LT tip: If your payer requires you to use a modifier to show which side the surgeon treated, append modifier LT (Left side) to 73030 and 20610.

ICD-9: Unless you have a more specific diagnosis, choose 716.91 (Arthropathy, unspecified; shoulder region).