Podiatry Coding & Billing Alert

Question: An established patient presented to the office with ankle tendonitis. The podiatrist conducted a problem-focused history and examination. He relieved the pain and reduced the inflammation of the affected area by applying R.I.C.E. (rest, ice, compression and elevation). What ICD-9 and CPT codes should I report?

Answer: You may report ankle tendonitis -- an inflammatory condition -- using the ICD-9 code 727.06 (Tenosynovitis of foot and ankle). This condition is caused by excess stress being placed on the posterior tibialis tendon.

For the E/M, you should bill 99212 (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 problem focused history; a problem focused examination, and straightforward medical decision making; Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). Straightforward medical decision making (MDM), with an expanded problem focused history/exam and a problem focused history/exam makes the MDM the driving factor in meeting an established patient's 2 of 3 key components' requirement for 99212.