EM Coding Alert

Consider patient status to choose accurate E/M service code.

If you work with a podiatrist, you probably encounter a lot of toe injuries. Make sure you know how to report the injury, select the correct evaluation and management (E/M) service code, and document the X-ray service.

Can you code this scenario from beginning to end? Don’t forget to seek the correct CPT^® and ICD-10-CM codes for this claim.

Check the Encounter Notes

Scenario: An established patient is experiencing pain in their right fifth toe. The patient stubbed their toe on a metal rolling cart. The patient has mild edema and swelling in the toe. They have been wearing a brace for the pain. The patient also complains of pain from ingrown toenails in both great toes. The podiatrist performed three X-ray views of the patient’s foot to make sure there was no fracture. The podiatrist did not see a fracture, so they applied buddy splinting to the fifth toe to help with the pain. The podiatrist examined the patient and noted that they did have ingrown toenails in the great toes. The patient will continue vinegar soaks and creams for the ingrown nails. The podiatrist spent 23 minutes on the date of the encounter with the patient. The podiatrist also performed a medically appropriate history of the patient.

Nail Down Appropriate CPT^® Codes

Office visit: For the E/M service, you should report 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.)

Code 99213 is the correct option in this instance because, according to the medical documentation, the podiatrist spent 23 minutes with the patient. The podiatrist also performed a medically appropriate history and exam. This information all fits with code 99213’s descriptor.

Established patient: You should note that in this case, the patient is established, which is an important detail you must consider when reporting E/M codes.

For an established patient, you should look to codes 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 10-19 minutes of total time is spent on the date of the encounter.) to 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.).

New patient: On the other hand, for a new patient, you would have looked at codes 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter.) to 99205 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 60-74 minutes of total time is spent on the date of the encounter.).

X-ray: For the X-ray service, you should report 73630 (Radiologic examination, foot; complete, minimum of 3 views) and append modifier RT (Right side).

You would report 73630 because the podiatrist documented that they took three X-ray images of the patient’s foot. According to 73630’s code descriptor, to report this code, the physician must have taken a minimum of three X-ray images.

Narrow Down ICD-10-CM Options

Once they finished taking the X-rays, the podiatrist found that the patient had not fractured their foot. The podiatrist diagnosed the patient with localized edema — R60.0 (Localized edema). The podiatrist also diagnosed the patient with ingrown nails — L60.0 (Ingrowing nail).

Important: If the patient did have a fracture, you would need to document the date of injury and if it was work related or due to an accident, says Jeri L Jordan, CPC, billing manager at Hampton Roads Foot and Ankle in Williamsburg, Virginia.

Edema defined: When a patient has an edema, they have a lot of fluid in their subcutaneous tissues. The edema can be localized or systemic.

Put the Claim Together

In summary, for this encounter, you should report the following codes:

• 73630-RT
• 99213
• R60.0
• L60.0.