Orthopedic Coding Alert

Question: A patient returns for re-evaluation of her plantar fasciitis and a second cortisone injection (3 mg Celestone Soluspan). She received the first injection 10 days earlier, and the surgeon told her she might need two more injections to resolve her symptoms. She reported that her heel pain had reduced by half, and the surgeon advised her to continue her stretching exercises and keep weight- bearing activities to a minimum. Which CPT, HCPCS and ICD-9 codes should I report? May I report an E/M service?

Wyoming Subscriber

Answer: You should not report an E/M code for this visit.

Reason: The patient presented for a scheduled second injection, offered no significant interval history, and follow-up treatment remained the same. In other words, the orthopedist didn't provide a separately identifiable E/M service.

Instead, you should report the injection with 20550 (Injection[s]; single tendon sheath or ligament, aponeurosis [e.g., plantar "fascia"]).

Report one unit of Celestone Soluspan with J0702 (Injection, betamethasone acetate 3 mg and betamethasone sodium phosphate 3 mg).

For the diagnosis, you should report the plantar fasciitis with 728.71 (Other fibromatoses; plantar fascial fibromatosis).

The patient also noted heel pain, so you may report 729.5 (Pain in limb) as a secondary diagnosis.