Primary Care Coding Alert

 Question: An established patient reports to the FP complaining of pain and swelling in her right knee. The physician diagnoses a meniscal tear during the course of a level-three E/M service and refers the patient to a specialist. How should I code this encounter?

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 Answer: There are two types of tears, and you-ll need to check the notes to see which type of tear this patient had before coding this scenario.

 Why? Your ICD-9 code choice depends on it.
On the report, you should see documentation that the patient has torn one of two knee menisci:
 - medial meniscus, on the inside of the knee
 - and/or lateral meniscus, located on the outside of the knee.

 These menisci serve as shock absorbers for the knee but are easily torn as a result of wear and tear by athletes. Patients may also tear the menisci as a result of trauma, such as twisting the knee or squatting. 

 Option 1: If the patient suffered a medial meniscus tear, you should report 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem-focused history; an expanded problem-focused examination; and medical decision-making of low complexity) for the E/M service -- with 836.0 (Tear of medial cartilage or meniscus of knee, current) to represent the tear.

 Option 2: If the patient suffered a lateral meniscus tear, you should report 99213 for the E/M service with 836.1 (Tear of lateral cartilage or meniscus of knee, current) to represent the tear.

 Option 3: If the notes do not specify the injury as medial or lateral, you should report 99213 for the E/M service with 836.2 (Other tear of cartilage or meniscus of knee, current) to represent the tear.