Orthopedic Coding Alert

Pre-procedure E/M could increase your code count.

When your orthopedist performs arthrocentesis/aspiration/injection on a patient's joint or bursa, you need to be on the lookout for other services you might be able to code during the encounter.

Read on for an example in which you'd report more than one code for your provider's arthrocentesis/aspiration/injection services.

Look Out for E/M-25

There will be times when the surgeon performs an evaluation and management (E/M) service ahead of the arthrocentesis/aspiration/injection. If you can prove that the E/M was a significant, separately identifiable service from the arthrocentesis/aspiration/injection - and it meets all of the qualifications of an E/M code - then you might be able to report the E/M separately with 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.

Example: A new patient reports to the orthopedist complaining of several issues with his right shoulder; limited range of motion (ROM), constant pain, swelling, etc. After an E/M that included an expanded problem focused history, a detailed examination, and medical decision making (MDM) of low complexity, the orthopedist decides to perform a shoulder arthrocentesis. The operative note does not mention guidance.

For this example, you'll likely be able to report the following - provided you can prove the separate E/M based on the operative report:

• 20610 (Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance) for the arthrocentesis
• modifier RT (Right side) appended to 20610 to indicate laterality, if the payer requires it.
• 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; Straightforward medical decision making ...) for the E/M
• modifier 25 appended to 99202 to show that the E/M and arthrocentesis were separate, significantly identifiable services.