Orthopedic Coding Alert

Question: A new patient reports to the orthopedist complaining of left shoulder pain. The provider performs an evaluation and management (E/M) service that lasts 43 minutes and involves low-level medical decision making (MDM). Based on the E/M, the orthopedist performs a computed tomography (CT) on the patient’s shoulder with computed tomography (CT). Our practice does not own the CT equipment that the provider used. Final diagnosis was solitary bone cyst, left shoulder. How should I report this encounter?

Maine Subscriber

Answer: 

On the claim, you’ll report:

• 73201 (Computed tomography, upper extremity; with contrast material(s)) for the X-ray.
• Modifier 26 (Professional component) appended to 73201 to show that you are only coding for the professional component of the CT scan.
• 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 the E/M.
• 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 99203 to show that a significant, separately identifiable E/M preceded the CT scan.
• M85.412 (Solitary bone cyst, left shoulder) appended to 73201 and 99203 to represent the patient’s injury.

FYI: For coders who are unfamiliar with this condition, “a solitary bone cyst of the … shoulder, also known as a simple bone cyst, is a benign, empty or fluid filled cavity in bone that can weaken it,” according to Codify by AAPC.