Orthopedic Coding Alert

Question: How would you code this scenario?

1. The patient was seen as an orthopedic consultation at the hospital for a septic wrist and the wrist was aspirated. I used 99254-25 (initial inpatient consultation for a new or established patient ... -significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) and 20600 (arthrocentesis, aspiration and/or injection; small joint, bursa or ganglion cyst [e.g., fingers, toes]).

2. The patient was seen in followup to the ortho consult at the hospital three days later, and wrist was re-aspirated. I used 99261-25 (follow-up inpatient consultation for an established patient ... -significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) and 20600-58 (arthrocentesis, aspiration and/or injection; small joint, bursa or ganglion cyst [e.g., fingers, toes, -staged or related procedure or service by the same physician during the postoperative period]).

3. The patient was seen six days later at a nursing home for evaluation only.

4. The same patient was seen three days later while in the dialysis unit at the hospital as an out-patient for re-evaluation and attempted aspiration, first with a needle and then with an incision and drainage, and the wound was packed.

5. The next day the patient was seen again at the nursing home for re-evaluation and admitted to the hospital the same day for irrigation and debridement of the left wrist joint and of the extensor surface of the left forearm.

Colorado Subscriber

Answer: For the aspiration of the wrist, 20605 (arthrocentesis, aspiration and/or injection; intermediate joint, bursa or ganglion cyst (e.g., temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa) is better than 20600. Code 20605 has 0 global days, so the -58 modifier (staged or related procedure or service by the same physician during the postoperative period) would not be necessary for the second aspiration three days later. Use the -RT or -LT modifier instead to indicate which wrist. Code 99254 with the -25 modifier is accurate.

For the followup consult, 99231 (subsequent hospital care, per day, for the evaluation and management of a patient ... ) with modifier -25 is more accurate. Your orthopedic surgeon has assumed care of the patient with regard to his or her wrist injury, therefore the followup is no longer a consultation.

For the nursing home visits, use 99301-99303 (evaluation and management of a new or established patient involving an annual nursing facility assessment ...) or 99311-99313 (subsequent nursing facility care, per day, for the evaluation and management of a new or established patient ...). For the incision and drainage, use 25028 (incision and drainage, forearm and/or wrist; deep abscess or hematoma) and the arthrotomy code 25101 (arthrotomy, wrist joint; with joint exploration, with or without biopsy, with or without removal of loose or foreign body). Last, for the hospital admission code, use 99221-99223 (initial hospital care, per day, for the evaluation and management of a patient ...). Because 25028 has a global period of 90 days, there is no additional code to accompany the hospital visit.