- A 38-year-old female patient returns to the practice for the second of three hyaluronate sodium injections of the left knee. The patient states the pain is somewhat better after her last injection. Her weight is 165 lbs., her height is 5 feet 6 inches, and her blood pressure is 120/81. After discussing the risks of the knee injection with the patient, the patient is prepped for the injection. Using sterile technique with a 22-gauge needle under ultrasound guidance, 2 cc of lidocaine and 60 mg of methylprednisolone acetate are injected; 47 cc of clear amber fluid was aspirated from the left knee. What CPT code(s) should be used for this encounter?
- 20610, 76942
- 20611, 76942
- ICD-10 coding guidelines state that it is allowable to code both primary general osteoarthritis (M15.0) and bilateral primary osteoarthritis of the hip (M16.0) for the same encounter.
- Should all comorbidities for every visit be coded on each claim?
- A 55-year-old male patient returns to the office for a follow-up visit for his rheumatoid arthritis (RF negative) and primary osteoarthritis. The patient states he has no pain and no swelling of the joints. A comprehensive history is taken, a comprehensive examination is done, and the medical decision making is of low complexity. How should this encounter be coded?
- A 73-year-old female patient returns for a follow-up visit for her primary generalized osteoarthritis. She is seeing the physician assistant (PA) today. She reports that she is experiencing joint pain in her knees with pain severity of 6 out of 10. She was prescribed tramadol for her pain, but reports that it causes nausea when she takes it. The patient has normal vital signs, her height is 5 feet 10 inches, her weight is 190 lbs., she has a BMI of 28.5, and her temperature is 97º F. Her lungs are clear. The heart has a regular rate and rhythm with no murmurs, frictions or rubs. She has no masses or tenderness in her abdomen. Her right knee has crepitus and mild tenderness on extreme flexion, but no warmth or effusion. Her left knee is unremarkable with full range of motion and no tenderness.
1) Bilateral primary osteoarthritis of knees (M17.0)
2) Nausea without vomiting (R11.0)
Plan: The PA decides to stop the tramadol and prescribes 500 mg of naproxen for the patient’s pain. She is counseled on the benefits of daily exercise and weight loss in the management of her osteoarthritis. She is given suggestions on how to incorporate daily physical activity into her schedule, along with recommendations to reduce fat and calorie intake. She is requested to return in three months for a follow-up appointment, sooner if any problems arise. Can this visit be billed as incident to?