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Question: I’m the newest coder in my orthopedic office and I need some help. How should I code the following procedure notes?

Procedure notes: A 62-year-old patient presents with pain and some swelling in the left wrist which is consistent with de Quervain’s tenosynovitis. After performing a brief history and exam, Dr. Rey suggests the injection of a corticosteroid, which they deem medically necessary to reduce the pain and inflammation in the extensor tendon sheath.

Under sterile techniques, a mixture of 1 mL of triamcinolone acetonide (40 mg/mL) and 1 mL of 1 percent lidocaine is injected into the tendon sheath of the abductor pollicis longus and extensor pollicis brevis tendons at the left wrist. The patient tolerated the procedure well.

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Answer: You should code 20550 (Injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar “fascia”)) for the first injection. You’ll also want to append modifier LT (Left side) to indicate the injection took place in the left wrist of the patient. Next, assign 20550 appended with modifiers LT and 59 (Distinct procedural service) to report the second injection.

Report 4 units of HCPCS Level II code J3301 (Injection, triamcinolone acetonide, not otherwise specified,10 mg) for the injection supply.

Lastly, assign M65.4 (Radial styloid tenosynovitis [de Quervain]) as the diagnosis code.

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