Podiatry Coding & Billing Alert

Question: How should I determine the evaluation and management (E/M) level with a cortisone injection coded to 20600?

For example, a presents for a foot pain problem and the podiatrist decides to perform a minor office procedure such as a foot cortisone injection on the same day as the visit. Does the overall personal health status of the patient matter for the E/M level of risk? Would the level of risk change if the patient was an 85-year-old uncontrolled diabetic with comorbidities as opposed to a healthy 50-year-old with no identifiable health issues?

AAPC Forum Participant

Answer: The level of risk for a procedure such as 20600 (Arthrocentesis, aspiration and/or injection, small joint or bursa (eg, fingers, toes); without ultrasound guidance) is specific to the patient and procedure. But the most important consideration in determining risk level in a medical decision making (MDM) calculation is the provider’s own assessment.

For example, E/M guidelines for 2023 state: “for the purpose of MDM, level of risk is based upon consequences of the problem(s) addressed at the encounter when appropriately treated. … The risk of patient management criteria applies to the patient management decisions made by the reporting physician or other qualified health care professional as part of the reported encounter.”

Or, as an AMA E/M FAQ puts it, “Risk for any procedure depends on the specific patient-risk factors and circumstances as they are assessed by the physician or other QHP. For example, a procedure may be deemed as high risk for a patient because of his or her specific circumstances, while the same procedure may be assessed as moderate or low risk for a different patient” (https://www.ama-assn.org/practice-management/cpt/ cpt-evaluation-and-management-em-revisions-faqs).

In other words, patient circumstances and procedure risks do factor into the calculation. But ultimately, the determination of the risk level in MDM calculations is the provider’s, as “definitions of risk are based upon the usual behavior and thought processes of a physician or other qualified health care professional” per the revised E/M guidelines for 2023.