Orthopedic Coding Alert

Question: Encounter notes that a patient reports to the orthopedist with complaints of pain and tenderness on the inner side of the right elbow extending into the forearm. The pain can worsen with certain movements, such as gripping or lifting objects.

During an office evaluation and management (E/M) service, the orthopedist assesses the location and severity of the pain; checks for tenderness and swelling around the inner side of the elbow; and evaluates the range of motion of the elbow, wrist, and fingers.

The provider then performs a magnetic resonance imaging (MRI) without contrast materials followed by contrast materials and further sequences. Final diagnosis is “R golfer elbow.” The orthopedist recommends physical therapy (PT) for treatment and sends the patient home. Notes indicate that the orthopedist performed straightforward medical decision making (MDM) during the E/M.

How should I report this encounter?

Michigan Subscriber

Answer: On this claim, you should report:

• 73223 (Magnetic resonance (eg, proton) imaging, any joint of upper extremity; without contrast material(s), followed by contrast material(s) and further sequences) for the MRI
• 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 total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.) for the E/M
• M77.01 (Medial epicondylitis, right elbow) appended to 73223 and 99203 to represent the patient’s injury

More on Dx: Golfer’s elbow, also known as medial epicondylitis, is a condition that causes pain and inflammation in the tendons that connect the forearm muscles to the inside of the elbow. Despite its name, it can occur in individuals who don’t play golf. It’s called golfer’s elbow because the repetitive swinging motion of a golf club can strain these tendons, leading to the condition.