Orthopedic Coding Alert

Question: Encounter notes indicate that the physician performed a level-three evaluation and management (E/M) service for an established patient. They then injected a pair of ganglion cysts; one on the patient’s right wrist and the other on the patient’s right hand. How should I report this encounter?

Illinois Subscriber

Answer: You’ll need three CPT^® codes, two diagnosis codes, and two modifiers to make this claim fly. On your claim, report:

• 20612 (Aspiration and/or injection of ganglion cyst(s) any location) for the first injection
• M67.431 (Ganglion, right wrist) appended to 20612 to represent the patient’s wrist cyst
• 20612 with modifier 59 (Distinct procedural service) appended for the second injection
• M67.441 (Ganglion, right hand) appended to 20612-59 to represent the patient’s hand cyst
• 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 the E/M was significant and separate from the injections

Why 59? You might be wondering why you’d report a pair of injections with modifier 59 instead of 20612 x 2. Per CPT^®, “To report multiple ganglion cyst aspirations/ injections, use 20612 and append modifier 59.”