Neurology & Pain Management Coding Alert

Question: During an office outpatient evaluation and management (E/M) service for a new patient, the provider diagnosed tarsal tunnel syndrome, prescribed rest and nonsteroidal anti-inflammatory drugs (NSAIDs) for the patient and instructed her to follow up if pain persisted. Medical decision making (MDM) was low and the visit lasted 24 minutes. I must admit I haven’t coded for tarsal tunnel syndrome before, and the new E/M coding rules have me on shaky ground. So I guess I have two questions; what E/M and diagnosis codes should I report for this scenario?

Pennsylvania Subscriber

Answer: First, we’ll break down the E/M. If you code according to time, you’ll choose 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.). Coding by MDM, however, nets you 99203 (… 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.).

The verdict: Report 99203 for the E/M — provided you can prove low MDM in the notes.

Now, to the tarsal tunnel coding. Since you’ve not coded for this condition, a little background: “Tarsal tunnel syndrome refers to compression of the posterior tibial nerve or its branches, which causes numbness, pain, and/or weakness of the lower leg and foot,” according to Codify.

You’ll choose from the following ICD-10 codes for this diagnosis:

• G57.50 (Tarsal tunnel syndrome, unspecified lower limb)
• G57.51 (… right lower limb)
• G57.52 (… left lower limb)
• G57.53 (… bilateral lower limbs)

The verdict: Go back and check the notes for more information regarding the specifics of the patient’s tarsal tunnel syndrome. If that fails, check with your provider. If that fails, choose G57.50 as a last resort.