Orthopedic Coding Alert
Scour Notes for Every Osteomyelitis Dx Detail
Question: During a level-three office evaluation and management (E/M) service for a new patient, the provider diagnoses acute hematogenous osteomyelitis in the patient’s hand. How should I report this encounter? AAPC Forum Subscriber Answer: The E/M is easy enough: 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 your provider’s services. The best ICD-10 code, however, isn’t clear with the information provided. Do this: Go back and check the notes for indications of laterality on the osteomyelitis. Then, choose one of the following diagnosis codes to append to 99203: 
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