Revenue Cycle Insider

Question: An established patient presented to their podiatrist for treatment of their plantar fasciitis. The patient was experiencing sharp pain in their foot when walking. Conservative treatments, such as rest, ice, stretching, and over-the-counter (OTC) nonsteroidal anti-inflammatory drugs (NSAIDs), didn’t provide relief. After examining the patient’s feet, the podiatrist injected the right foot with a corticosteroid.

What codes should I report for the encounter?

Virginia Subscriber

Answer: You’ll need one ICD-10-CM code, one procedure code, and one HCPCS Level II code to report this encounter. Let’s start with the procedure code.

Assign either 20550 (Injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar “fascia”)) or 20551 (Injection(s); single tendon origin/insertion) depending on where the podiatrist injected the patient’s plantar fascia. You’ll assign 20550 if the provider injected the medication directly into the tendon, whereas 20551 is correct if the administration occurred where the tendon attaches to the bone.

You will also need to report the appropriate HCPCS Level II code to request reimbursement for the drug supply or medication injected into the tendon. Double-check your documentation or query the provider for the specific drug and dosage to assign the correct code.

Lastly, you’ll assign M72.2 (Plantar fascial fibromatosis) to report the patient’s plantar fasciitis as the reason for the visit.

Mike Shaughnessy, BA, CPC, Development Editor, AAPC