Revenue Cycle Insider

Question: A new patient reports to the neurosurgeon complaining of pain in their left leg, beginning at the buttocks and radiating down their lower left leg. During the history portion of the evaluation and management (E/M) service, the patient notes that the pain has been going on “for about a month and a half,” even causing foot numbness at times. The surgeon examines the patient and performs a straight leg raise test. The patient experiences shooting pain down the left leg at about 60 degrees. After ordering a lumbar MRI without contrast material followed by contrast material, the surgeon diagnoses left-sided sciatica. Our surgeon interpreted the MRI and we used our own equipment for the test. How should I report this encounter? Is there a code for the straight leg raise test?

Massachusetts Subscriber

Answer: There is not a separate code for the straight leg raise test; you’ll figure that into the level of service when choosing your office/outpatient E/M code. If the surgeon performs similar sciatica-related tests — such as the seated straight leg raise, the Braggard test, or the slump test — during an encounter, you’ll also roll those into the overall E/M work units.

On your claim, you should report:

• 72158 (Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; lumbar) for the MRI
• A code from the 99202-99205 (Office or other outpatient visit for the evaluation and management of a new patient …) set for the E/M based on encounter notes
• Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure) appended to the E/M to show that the E/M and MRI were significant, separately identifiable services
• M54.32 (Sciatica, left side) appended to 72158 and the E/M code to represent the patient’s sciatica.

Chris Boucher, MS, CPC, Senior Development Editor, AAPC