EM Coding Alert

Question: A new patient reports to the orthopedist complaining of left shoulder pain. The provider performs an evaluation and management (E/M) service that lasts 43 minutes and involves low-level medical decision making (MDM). Based on the E/M, the orthopedist orders a computed tomography (CT) on the patient’s shoulder with contrast. The CT was performed and interpreted at another facility. Final diagnosis was solitary bone cyst, left shoulder. How should I report this encounter?

Illinois Subscriber

Answer: On the claim, you’ll 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 time for code selection, 30-44 minutes of total time is spent on the date of the encounter.) for the E/M.
• M85.412 (Solitary bone cyst, left shoulder) appended to 73201 and 99203 to represent the patient’s injury.

FYI: For coders who are unfamiliar with this condition, “a solitary bone cyst of the … shoulder, also known as a simple bone cyst, is a benign, empty or fluid filled cavity in bone that can weaken it,” according to Codify by AAPC.