Orthopedic Coding Alert

Question: Encounter notes indicate that the surgeon performed an outpatient evaluation and management (E/M) service for a new patient that featured moderate medical decision making (MDM); total encounter time was 53 minutes. Then, the provider performed a posterior spinal osteotomy of three cervical vertebral segments. How should I report this encounter?

New Jersey Subscriber

Answer: You need to report a primary osteotomy code specific to the segment of the spine the provider treated, and then you’ll need add-on codes to account for the segments. On the claim, report:

• 22210 (Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; cervical) for the cervical osteotomy.
• +22216 x 2 appended to 22212 to account for the other segments that the provider treated with osteotomy.
• 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.) for the E/M service.
• Modifier 57 (Decision for surgery) appended to 99215 show that surgery followed the E/M service. (Though this E/M does not meet the criteria for the MDM portion of 99215, it does meet the criteria for the time portion of 99215. Remember in 2021, you only need one of these elements to report an E/M code.)