Orthopedic Coding Alert

Question: The orthopedist performed an office evaluation and management (E/M) service for an established patient. The E/M encounter lasted 37 minutes and included moderate-level medical decision making (MDM). The surgeon then performed radical excision of synovia of the left wrist. How should I report this encounter?

Montana Subscriber

Answer: For this encounter, report:

• 25115 (Radical excision of bursa, synovia of wrist, or forearm tendon sheaths (eg, tenosynovitis, fungus, Tbc, or other granulomas, rheumatoid arthritis); flexors) or 25116 (… extensors, with or without transposition of dorsal retinaculum) for the synovia of wrist excision, depending on encounter specifics.
• Modifier LT (Left side) appended to 25115/25116 to indicate the laterality of the surgery.
• 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.) for the E/M service.
• Modifier 57 (Decision for surgery) appended to 99214 to show that a significant, separately identifiable E/M occurred before surgery.