Podiatry Coding & Billing Alert

Question: An established patient presented to the office with ankle tendonitis. The podiatrist conducted a problem-focused history and examination. He relieved the pain and reduced the inflammation of the affected area by applying R.I.C.E. (rest, ice, compression and elevation). What ICD-9 and CPT codes should I report?Answer: You may report ankle tendonitis -- an inflammatory condition -- using the ICD-9 code 727.06 (Tenosynovitis of foot and ankle). This condition is caused by excess stress being placed on the posterior tibialis tendon.For the E/M, you should bill 99212 (Office or other outpatient visit for the evaluation and management of an established patient which requires at least 2 of these 3 key components: a problem focused history; a problem focused examination, and straightforward medical decision making; Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). Straightforward medical decision making (MDM), with an [...]