Orthopedic Coding Alert

Question: Encounter notes indicate that the provider saw a patient in the office for pain in her finger. After an evaluation and management (E/M) service that included low medical decision making (MDM) and lasted 27 minutes, the provider diagnosed trigger finger. They then performed a tendon sheath injection to treat the injury. How should I code this encounter?

Idaho Subscriber

Answer: You should report 20550 (Injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar “fascia”)) for the tendon sheath injection. Then report 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 30-44 minutes of total time is spent on the date of the encounter.) for the E/M. Also, append 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) to 99203 to show that the E/M was a distinct and separate service from 20550.

Dx coding: Based on the information you’ve provided, selecting the correct ICD-10 code is going to be tough for this encounter. Trigger finger ICD-10 codes are categorized by which finger is affected (thumb, index, middle, ring, little) and which side the injury occurs on (left or right). So if the notes indicate that a patient has trigger finger in her right index finger, you’d report M65.321 (Trigger finger, right index finger) for the injury.

Do this: Check the notes — or ask the provider if you can — for any more information on the trigger finger injury, and then select a specific ICD-10 code. If this is all the information you’re going to have, then append M65.30 (Trigger finger, unspecified finger) to 20550 and 99203 to represent the patient’s injury.