How strong are you at coding for multiple E/M services? Test your knowledge and see if you can determine the right way to code this scenario. Hint: There are CPT, HCPCS, and ICD-10-CM codes needed.
Question: A 51-year old female patient is seen for a follow-up visit for her seronegative rheumatoid arthritis that is affecting multiple sites. There is no organ or systems involvement. The physician performed a detailed history and examination, and the medical decision making was of moderate complexity.
During the encounter, the patient complained of swelling in the right knee with throbbing knee pain. She states her pain is a 9 on a 10-point scale and her pain has gotten gradually worse over the past five weeks. Ibuprofen has not relieved the pain. The musculoskeletal exam is normal except for the right knee, which is tender to the touch and swollen. Patient is taking sulfasalazine 500 mg tablets by mouth, 3 times a day. Along with the severe pain in the right knee, the knee lacks 5 degrees of full extension, and the range of motion is less than 45 degrees. Her gait is unstable, and she leans to the right side. Secondary osteoarthritis is suspected, and an x-ray is ordered to confirm the diagnosis.
Patient elects to have a knee joint injection for the pain, and 80 mg of methylprednisolone acetate is administered via ultrasound guidance due to the patient’s weight of 300 pounds. A permanent recording of the ultrasound guidance is entered in the patient’s record. The patient was also given a prescription for the pain and is to return in four weeks.
What CPT, HCPCS, and ICD-10-CM codes should be reported?
- CPT/HCPCS: 99214-25, 20611-RT, J1040
- ICD-10: M06.09, M25.561
The patient is being seen for a follow-up visit for the seronegative rheumatoid arthritis affecting multiple sites. There is no organ or systems involvement. This is a follow-up visit, so the patient is established.
CPT Codes – Locate and Verify
Followup visit. Look in the CPT coding manual Index under Outpatient services, established patient, 99211-99215.
Verified in the Tabular, CPT 99214 is the appropriate code.
99214, 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 detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 25 minutes are spent face-to-face with the patient and/or family.
We know CPT 99214 is correct, because the documentation states “detailed history and examination, and the medical decision making was of moderate complexity.”
Although only 2 of the 3 components need to be met to report 99214, 3 of the 3 components were met in this case.
New problem. A new problem was assessed and treated during the follow-up visit, which was the right knee pain. This supports the need for a separate E/M code, according to the CPT coding guidelines.
Therefore, Modifier 25 should be added to CPT code 99214 (99214-25) to indicate a significant, separately identifiable Evaluation and Management service by the same physician or other qualified health care professional on the same day of the procedure or other service.
This new problem is significant in that it requires treatment and a return visit.
Injection. An injection of methylprednisolone acetate was administered in the patient’s knee joint. This procedure is used to help control the pain and swelling in the joint.
In certain cases, there is a significant amount of fluid buildup, or an effusion within the joint, and this fluid is first aspirated to remove the pressure, according to John Hopkins Rheumatology.
Joint aspiration is also referred to as arthrocentesis: arthr/o means joint; -centesis means surgical puncture. An arthrocentesis or aspiration is a surgical puncture of a joint to remove fluid, pus, or blood. The purpose is to diagnose the cause of joint effusion and/or to reduce the pain caused by the excess fluid.
The injection procedure is reported with CPT 20611. Because the injection was administered on the right knee, the modifier -RT must be appended to CPT 20611, making it 20611-RT.
For more information on this procedure, see the video at the bottom of this post.
CPT code 20611 can be found in the CPT coding manual Index under Injection, joint 20600-20611.
In the Tabular, 20611 refers to Arthrocentesis, aspiration and/or injection, major joint or bursa (e.g., shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting.
According to the guidelines:
- Do not report 20610, 20611 in conjunction with 27369, 76942.
- If fluoroscopic, CT, or MRI guidance is performed, see 77002, 77012, 77021.
HCPCS Code – Locate and Verify
The drug itself, methylprednisolone acetate, needs to be reported. Looking in the HCPCS coding manual Index under Methylprednilosone, acetate, it refers us to J1020-J1040.
In the Tabular, J1040 refers to Injection, methylprednisolone acetate, 80 mg. This code is listed under Drugs Administered Other Than Oral Method.
Locate and Verify
Seronegative rheumatoid arthritis. Patient has seronegative rheumatoid arthritis of multiple sites without organ or systems involvement and should be reported with M06.09, Rheumatoid arthritis without rheumatoid factor, multiple sites.
This code can be found in the ICD-10-CM coding manual Index under Arthritis, rheumatoid, seronegative, multiple sites M06.09. This code can then be verified in the Tabular.
Osteoarthritis. The secondary osteoarthritis has NOT been confirmed because the physician does not have the radiology report yet. Therefore, the pain should be reported.
In the ICD-10-CM coding manual Index, see Pain, joint, knee M25.56-.
Verified in the Tabular, M25.561 refers to Pain in right knee.
According to the 2021 ICD-10-CM Coding Guidelines:
“Codes that describe symptoms and signs, as opposed to diagnoses, are
acceptable for reporting purposes when a related definitive diagnosis has not
been established (confirmed) by the provider.”
Knee Joint Injection Demonstration
In the video below, Elizabeth Marshall, MD, demonstrates how a knee injection is performed. Although it’s a little over 10 minutes long, start at about 6:50. She basically explains that they clean the area, insert the syringe of lidocaine into the knee to numb it and then they aspirate the fluid. They then remove the lidocaine syringe from the hub of the needle and put on the syringe with the medication to inject the medication into the joint.
Sometimes there is no fluid, so there is no need to aspirate, in which case only the injection of medication (steroid) is performed.
** This post has been updated to reflect the ICD-10-CM coding guidelines for FY 2021.**
- Best Treatment Options for Rheumatoid Arthritis
- Rheumatoid Arthritis in ICD-10-CM: It’s All in the Joints
- Taking the Pain Out of Gunshot Wounds