Podiatry Coding & Billing Alert

Question: The patient complains of ongoing right heel pain, especially when he first gets up from a sitting position or from bed in the morning. His symptoms usually get worse with prolonged walking. The patient’s symptoms came on gradually and are now worse. The podiatrist conducted a physical exam of the patient’s right and observed tenderness at insertion of plantar tendon at the right heel. X-rays of the right heel reveal a calcaneal bone spur at the area of the plantar tendon insertion. The podiatrist gives the patient a Cortisone injection to the right heel in the area of the bone spur/tendon insertion.

Maine Subscriber

Answer: You should report the following codes for this visit:

• 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 …) for the evaluation and management (E/M) visit.
• 73620 (Radiologic examination, foot; 2 views) for the X-ray.
• Modifier RT (Right side) appended to 73620 to indicate laterality, if the payer requires it.
• 20551 (Injection(s); single tendon origin/insertion) for the injection.
• Modifier RT (Right side) appended to 20551 to indicate laterality, if the payer requires it.
• J1030 (Injection, methylprednisolone acetate, 40 mg) for the drug supply.
• M72.2 (Plantar fascial fibromatosis) and M77.31 (Calcaneal spur, right foot) appended to 99203, 73620, and 20551 to represent the patient’s conditions.