Primary Care Coding Alert

Question: Our physician saw a new patient with a complaint of right-sided extremity pain emanating from his shoulder to his elbow, wrist, and the joints of his hand. During an evaluation and management (E/M) service that included an expanded problem-focused history and detailed examination, the physician prescribed rest and ibuprofen for the patient and told him to return in six weeks if the symptoms persisted. How should I code this encounter? Is there a single diagnosis code for all of the patient’s symptoms?

South Dakota Subscriber

Answer: There isn’t a single diagnosis code for this encounter, but there is a single CPT^® code: 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; straightforward medical decision making …).

As for the diagnosis codes you’ll append to 99202, your best bet is to list the following in anatomically descending order:

• M25.511 (Pain in right shoulder) to represent the patient’s shoulder pain.
• M25.521 (Pain in right elbow) to represent the patient’s elbow pain.
• M25.531 (Pain in right wrist) to represent the patient’s wrist pain.
• M25.541 (Pain in joints of right hand) to represent the patient’s hand pain.