Orthopedic Coding Alert

Question: A new patient reports with right knee pain, which the orthopedist suspects to be a possible ligament tear. The physician takes a detailed history and during the course of a detailed examination, she decides to perform a magnetic resonance imaging (MRI) with contrast material. The MRI didn’t confirm a knee tear, but she diagnosed a “grade 3 R knee sprain, lateral sublux patella.” How should I code this encounter?

Montana Subscriber

Answer: On the claim, you should report 73722 (Magnetic resonance (eg, proton) imaging, any joint of lower extremity; with contrast material(s)) for the MRI. Append modifier RT (Right side) to 73722 to indicate laterality, if the payer requires it.

Provided the notes prove that your physician also performed a significant, separately identifiable E/M, report the service with 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity …).

Append ICD-10 code S83.011 (Lateral subluxation of right patella) to 73722 and 99203 to indicate the patient’s knee sprain.