Orthopedic Coding Alert

Question: The provider conducts an office evaluation and management (E/M) service for a patient that lasts 38 minutes and includes low medical decision making (MDM). Based on the E/M, the provider decides to conduct a left hip arthroscopy. How should I report this encounter?

Utah Subscriber

Answer: It depends on the type of arthroscopy the provider performed. Go back and check the notes; if it was a diagnostic procedure, report 29860 (Arthroscopy, hip, diagnostic with or without synovial biopsy (separate procedure)) with modifier LT (Left side) appended to indicate laterality, if the payer requires it.

If, however, the arthroscopy was surgical, things get trickier. You’ll need to dive deep into surgical arthroscopy notes to find out exactly why the provider performed the surgery. Then, you’ll report one of the following codes:

• 29861 (Arthroscopy, hip, surgical; with removal of loose body or foreign body)
• 29862 (… with debridement/shaving of articular cartilage (chondroplasty), abrasion arthroplasty, and/or resection of labrum)
• 29863 (… with synovectomy)
• 29914 (… with femoroplasty (ie, treatment of cam lesion))
• 29915 (… with acetabuloplasty (ie, treatment of pincer lesion))
• 29916 (… with labral repair).

Note: Remember that 29914, 29915, and 29916 have a hashtag next to them in CPT^® 2021, meaning they were resequenced for clarity. They are, however, still part of the 29860 base code family. Don’t be thrown if these codes look out of place; they’re right where CPT^® wants them.

E/M coding: E/M level will depend on patient status. You’ll choose 99203 (Office or other outpatient visit for the evaluation and management of a new patient, 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.) if the patient was new and 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 time for code selection, 30-39 minutes of total time is spent on the date of the encounter.) if the patient was established. Remember, you have the freedom to choose your office/outpatient E/M code based on total E/M encounter time or MDM level.

Modifier alert: No matter which arthroscopy-E/M code combination you report, be sure to append modifier 57 (Decision for surgery) to the E/M code to show that the arthroscopy was a separate service from the E/M.