Coding Corner Answer

99213-25, 20552, J2001x2. Diagnosis 726.0, 729.1.

The E/M visit was a level three because the history and exam were expanded and problem focused. Office visits for the evaluation and management of an established patient require only two of three key components for a level-three designation. This visit met two of the key components; the medical decision-making was straightforward and was not a factor in the overall coding.

Although there were two injections, you would not code the 20552×2. Keep in mind that this code is based on the number of muscles, not injections. The CPT manual defines 20552 as, “Injection(s); single or multiple trigger point(s), one or two muscle(s).”

The modifier -25 is added because a separately identifiable E/M visit was performed on the same day as a procedure.

The ICD-10 page on the Centers for Medicare & Medicaid Services (CMS) website features a countdown clock that shows the time left until Oct. 1, 2015, the date on which compliance with the new code set becomes mandatory. By the time this issue goes to press, the clock will read 90 or fewer days. Time…

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After 25 years, the American Medical Association (AMA) Current Procedural Terminology (CPT) office and outpatient evaluation and management (E/M) codes received a major overhaul. These changes, which went into effect Jan. 1, will help reduce administrative burden on providers and roll back some of the rigid requirements for E/M coding by simplifying the code selection…

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Coding Corner Answer

Coding Corner Answer

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