Primary Care Coding Alert

Question: An established patient with a plan of care in place for carpal tunnel syndrome (CTS) in her left wrist reports to the FP with wrist pain. The woman is wearing a splint, but says that she has not worn it consistently; further, she reports that she has not been attending her physical therapy (PT) sessions. She says her hand is tingling, her wrist hurts, and she has trouble using her fingers. After performing an expanded problem focused exam, the FP injects 40 mg of Depo-Medrol in the patients wrist. Then he puts the patients wrist back in the splint -- and reminds her that she should wear it regularly and attend her PT sessions. Is there enough evidence for a separate E/M service for this encounter?

North Dakota Subscriber

Answer: Its very likely; go back and check the encounter documentation to be sure, but it appears that your FP provided the patient a significant and separately identifiable E/M service.

The procedure code for carpal tunnel injection (CTI) has a global period of zero days. Therefore, you must be sure that the E/M is indeed separate before reporting the service. If the E/M service is inherent to the procedure, you should not separately report it.

CCIs take: Check out this explanation from Correct Coding Initiative (CCI) version 14.3: If a procedure has a global period of 0 or 10 days, it is defined as a minor surgical procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E/M service. However, a significant and separately identifiable E/M service unrelated to the decision to perform the minor surgical procedure is separately reportable.

From your description, it seems that the FP made a medical decision to perform the CTI prior to administering the shot. You mentioned the expanded problem focused exam, and the FPs decision to perform the CTI involved straightforward medical decision.

On the claim, report the following:

" 20526 (Injection, therapeutic [e.g., local anesthetic, corticosteroid], carpal tunnel) for the CTI

" 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; straightforward medical decision making &) for the E/M

" Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99212 to show that the E/M and injection were separate services

" 354.0 (Carpal tunnel syndrome) appended to 20526 and 99212 to represent the patients condition

" J1030 (Injection, methylprednisolone acetate, 40 mg) for the Depo- Medrol supply.