Pain Management Coding Alert

Question: Notes indicate that the PM provider saw a patient recovering from a traumatic rupture of the intervertebral disc. Notes indicate an evaluation and management (E/M) service that included a detailed history and examination, along with moderate-level medical decision making (MDM). Which CPT^® and ICD-10 codes should I submit for this encounter?

West Virginia Subscriber

Answer: First, we’ll address the E/M. You are missing one crucial element of the E/M encounter; patient status. Go back and check the encounter notes; then, choose 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 … ) if the patient is new and 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity … ) if the patient is established.

As with the E/M code choice, you’ll need more information on the exact location and nature of the rupture before adding an ICD-10 code to your E/M claim.

If the patient’s injury is to the cervical intervertebral disc, report S13.0XX_ (Traumatic rupture of cervical intervertebral disc).

If the patient’s injury is to the thoracic intervertebral disc, report S23.0XX_ (Traumatic rupture of thoracic intervertebral disc).

If the patient’s injury is to the lumbar intervertebral disc, report S33.0XX_ (Traumatic rupture of lumbar intervertebral disc).

Remember your place … holders: Regardless of the ICD-10 code you choose from those above, you’ll need to include a seventh character to represent whether the encounter for this particular injury is initial (A), subsequent (D), or sequela (S). In order for the code to reach the seven-digit mark, you’ll need to use placeholder ‘X’ for digits five and six.

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