Orthopedic Coding Alert

Question: An established patient suffering from rheumatoid myopathy with rheumatoid arthritis (RA) of the right foot reports to the orthopedist’s office. The orthopedist performs a level-four evaluation and management (E/M) service, takes a three-view right foot X-ray, and decides to perform a capsulotomy involving only medial release. How should I report this encounter?

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Answer: For this encounter, you should report:

• 28260 (Capsulotomy, midfoot; medial release only (separate procedure)) for the capsulotomy
• Modifier RT (Right side) appended to 28260 to indicate laterality
• 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 service
• Modifier 57 (Decision for surgery) appended to 99214 to show that the E/M led to the decision for surgery
• 73630 (Radiologic examination, foot; complete, minimum of 3 views) for the foot X-ray
• M05.471 (Rheumatoid myopathy with rheumatoid arthritis of right ankle and foot) appended to 28260, 99214, and 73630 to represent the patient’s condition.