Primary Care Coding Alert

 Question: An established patient with gamekeeper's thumb reports to the FP. The operative notes indicate the physician examined the thumb and index finger, made the diagnosis and immobilized the thumb. Can I report a separate E/M service in this scenario, and what CPT code should I report for the immobilization?

Idaho Subscriber

 Answer: Make sure that your physician's documentation indicates a separately identifiable E/M service that goes beyond what is incidental to the procedure.

 In the scenario you describe, the FP might perform history and physical exam elements that go beyond simply immobilizing the thumb, in which case you would report a low-level E/M code, such as 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem-focused history; a problem-focused examination; and straightforward medical decision-making).

 The answer to your second question depends on the immobilization technique the physician uses. When she performs the immobilization using an ACE bandage or other strapping material, report 29280 (Strapping; hand or finger) for the service.

 If the FP applies a thumb spica cast to immobilize the injury, report 29075 (Application, cast; elbow to finger [short arm]) for the service. No matter which CPT code you choose, include 842.12 (Sprains and strains of wrist and hand; hand; metacarpophalangeal [joint]) on the claim to represent the patient's thumb condition.