Orthopedic Coding Alert

Question: Encounter notes indicate that after an office evaluation and management (E/M) service that included moderate medical decision making (MDM) and lasted 44 minutes, the provider decided to perform a thoracic myelography via lumbar injection. Radiological supervision and interpretation are also noted in the record. How should I report this encounter?

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Answer: 

On the claim, report:

• 62303 (Myelography via lumbar injection, including radiological supervision and interpretation; thoracic) for the myelography.
• One of the following E/M codes, depending on patient status: 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.) if it’s a new patient, and 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.) if it’s an established patient.
• 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) appended to 99204 or 99215 to show that the E/M was significant and separately identifiable from the myelography.