Primary Care Coding Alert

Question: Encounter notes indicate that the provider met with a new patient complaining of pain in the right elbow. The provider performed an office evaluation and management (E/M) service that involves low-level medical decision making (MDM). After the E/M, the provider ordered a two-view elbow X-ray to rule out fracture. The final diagnosis was lateral epicondylitis. How should I report this encounter?

California Subscriber

Answer: Since MDM level has been established, you know the number of X-ray views, and the provider included laterality and the type of tennis elbow, coding is pretty straightforward.

CPT^® coding: On the claim, report 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/ or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.) for the E/M and 73070 (Radiologic examination, elbow; 2 views) for the X-ray, assuming the X-ray ordered by the physician (including both the technical and professional components) was provided by the practice and not done elsewhere. Then, append modifier RT (Right side) to 73070 to indicate laterality.

ICD-10 coding: When it comes to epicondylitis, you have two choices: M77.0- (Medial epicondylitis) or M77.1- (Lateral epicondylitis). Medial epicondylitis, also known as golfer’s elbow, is painful inflammation of the tendons that join the forearm muscles on the inner side of the elbow. Lateral epicondylitis, also known as tennis elbow, is painful inflammation of the tendons that join the forearm muscles on the outside of the elbow. Both injuries often occur due to overuse or repeated injury.

These are the codes available for each condition:

• M77.00 (Medial epicondylitis, unspecified elbow)
• M77.01 (Medial epicondylitis, right elbow)
• M77.02 (Medial epicondylitis, left elbow)
• M77.10 (Lateral epicondylitis, unspecified elbow)
• M77.11 (Lateral epicondylitis, right elbow)
• M77.12 (Lateral epicondylitis, left elbow).

Since your provider indicated the patient suffered lateral epicondylitis, or tennis elbow, and we can assume it’s in the right elbow, since that was the side with the pain, the ICD-10 code to append to 99203 and 73070 is M77.11.