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Orthopedic Coding Alert

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Code Stenosis First When it Prompts Surgery

Published on Thu May 06, 2021

Question: An established patient presents with cervical spinal stenosis C5-C6 and degenerative disc disease with myelopathy and radiculopathy; during the office evaluation and management (E/M) service, the surgeon and patient decided that they would treat the injury with surgery. Notes indicate that the E/M consisted of moderate-level medical decision making (MDM) and took 45 minutes. What CPT® and ICD-10 code(s) [...]
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