The correct way to bill this visit is:
99214-25, 20610, J7325 x10, 76881
Dx: 715.96, 787.02
This encounter is coded as 99214 because it included:
- Detailed history;
- Comprehensive examination—eight systems; and
- Medical decision making—moderate complexity (established problem, new problem with no additional workup; new prescription drug ordered).
The 20610 is coded for the intraarticular injection of the right knee. The diagnostic ultrasound of the right knee 76881 is a new code for 2011. The code description for the ultrasound is “ultrasound, extremity, nonvascular, real time with image documentation; complete.” According to the 2011 CPT manual, “A complete ultrasound examination of an extremity (76881) consists of real-time scans of a specific joint that includes examination of the muscles, tendons, joint, other soft tissue structures, and any identifiable abnormality.”
The office visit is allowed because the knee injection was a separate and significant problem the patient presented at the time of the visit.