Primary Care Coding Alert

Question: An established patient presents to the office complaining of pain in their right foot and toes, and pain in their left foot. The provider orders X-rays for both feet (3 views of the right foot, 2 views of the left foot). There is no indication of serious injury on the X-rays, so the physician recommends the patient take over-the-counter pain medication and rest their feet. Notes indicate that outside of the X-ray work, the provider performed an evaluation and management (E/M) service that involved low-level medical decision making (MDM). How should I code this encounter?

Minnesota Subscriber

Answer: On the claim, you’ll need to report the E/M, which as the notes indicate was deemed low-level for MDM, which translates to 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter.)

Next, you will need to report the pain in the right and left feet in relation to the E/M visit:

• M79.671 (Pain in right foot)
• M79.674 (Pain in right toe(s))
• M79.672 (Pain in left foot)

Last, you will need to report the X-rays and amend the pain codes to each:

• 73630 (Radiologic examination, foot; complete, minimum of 3 views) for the right foot X-ray with M79.671 and M79.674
• 73620 (… 2 views) for the left foot X-ray with M79.672