Orthopedic Coding Alert

Question: An established patient with severe spinal pain presented to the surgeon for evaluation. The surgeon ordered a four-view thoracic and lumbar spine X-ray and diagnosed age-related osteoporosis with a current pathological thoracic fracture. Beyond the imaging work, the encounter included a distinct evaluation and management (E/M) service supported by moderate medical decision making (MDM) and 34 minutes of time spent with the practitioner. How should I report this encounter?

Washington Subscriber

Answer: On the claim, you’d report:

• 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.) for the E/M portion
• 72083 (Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); 4 or 5 views) for the X-rays
• M80.08XA (Age-related osteoporosis with current pathological fracture, vertebra(e), initial encounter for fracture) appended to 99214 and 72083 to represent the patient’s fracture (Keep in mind that you need to report this code to the 7^th character with “A” indicating this as the initial encounter for fracture)

Make note: Remember that ordering and reviewing diagnostic imaging contributes to the MDM calculation for the E/M service. However, if the physician separately reports the interpretation of the X-ray, you cannot count that interpretation toward the data calculation for MDM.

Lindsey Bush, BA, MA, CPC, Production Editor, AAPC