Orthopedic Coding Alert

Question: During the course of a level-four evaluation and management (E/M) service for a new patient, the provider notes "shoulder and hip effusion, right-sided. Also knee effusion." How many diagnosis codes do I need for this encounter, and what exactly is "effusion"?

Florida Subscriber

Answer: You'll need three diagnosis codes to represent all the diagnoses for this 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a comprehensive history; a comprehensive examination; medical decision making of moderate complexity ...) claim:

• M25.411 (Effusion, right shoulder) for the shoulder effusion
• M25.451 (Effusion, right hip) for the hip effusion
• M25.469 (Effusion, unspecified knee) for the knee effusion.

This is as far as you can go, in terms of diagnosis specificity, with the notes you described. Since it did not appear that provider specified the knee effusion area in the notes, M25.469 is the best option.

Effusion definition: According to verywell.com, effusion is abnormal fluid build-up in the joints. When effusion occurs, the joints appear swollen. Effusion symptoms might also include joint pain, redness, warmth, and decreased range of motion, according to the website. While arthritis is the most common cause of effusion, viral infection or physical trauma could also cause the condition.