Orthopedic Coding Alert

Question: An established patient presents to the office complaining of pain in their right foot and toes, and pain in their left foot. The orthopedist and orders X-rays for both feet; a complete X-ray for the right foot, and a two-view X-ray for the left foot. There is no indication of serious injury on the X-rays, so the physician recommends the patient take over-the-counter pain medication and rest their feet. Notes indicate that outside of the X-ray work, the orthopedist performed an evaluation and management (E/M) service that involved low-level medical decision making (MDM). How should I code this encounter?

Minnesota Subscriber

Answer: You’re going to need three diagnosis codes total — but each CPT^® code will have different combinations of ICD-10 codes appended to them.

On the claim, report:

• 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter.) for the E/M
• M79.671 (Pain in right foot) appended to 99213 to represent the patient’s right foot pain
• M79.674 (Pain in right toe(s)) appended to 99213 to represent the patient’s right toes pain
• M79.672 (Pain in left foot) appended to 99213 to represent the patient’s left foot pain
• 73630 (Radiologic examination, foot; complete, minimum of 3 views) for the right foot X-ray
• Modifier RT (Right side) appended to 73630 to indicate laterality
• M79.671 and M79.674 appended to 73630 to represent the patient’s right foot/toes pain
• 73620 (… 2 views) for the left foot X-ray
• Modifier LT (Left side) appended to 73620 to indicate laterality
• M79.672 appended to 73620 to represent the patient’s left foot pain.