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You are here: Home / Articles / Coding Corner Answer

Coding Corner Answer

March 18, 2011 • By Staff

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March 2011
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  • Documentation History in Evaluation and Management Services

The correct way to bill this visit is:
99214-25, 20610, J7325 x10, 76881
Dx: 715.96, 787.02

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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.”

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The office visit is allowed because the knee injection was a separate and significant problem the patient presented at the time of the visit.

Filed Under: Billing/Coding, Practice Management Tagged With: Billing, Coding, Injection, joint, patient care, rheumatologistIssue: March 2011

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