CPT codes: 99214-25, 27096, J3301 x1
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ICD-9: 720.2, 720.0, 787.02
ICD-10: M46.1*, M45.9*, R11.0
This encounter is coded as 99214 because it includes:
- Detailed history;
- Comprehensive examination—eight systems counted; and
- Medical decision making—moderate complexity (established problem, new problem with no additional workup; new prescription drug ordered).
Keep in mind, the CT guidance is an inclusive component of the sacroiliac joint injection. The 2015 CPT code description for an SI joint injection is, “Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed.” If a CT or fluoroscopy imaging is not performed with the SI injection, then the procedure should be downcoded to 20552, which includes if ultrasound guidance is used for the imaging.
*The documentation of this encounter is not specific enough to get to the highest specificity of the ICD-10 code.
- ICD-10 code M46.1 is for sacroiliitis, not elsewhere classified. This code does not reach the highest level of specificity in ICD-10 and requires additional information. It will be important to include the region of the spine (e.g., lumbar, lumbosacral, sacral or sacrococcygeal) that was examined and injected.
- ICD-10 code M45.9 is ankylosing spondylitis of unspecified sites on the spine. This code also does not reach the highest level of specificity for correct coding. To code the most accurate level of specificity for this diagnosis, it will be necessary to include if it is multiple sites, lumbar or lumbosacral.
Documentation is vital to coding for ICD-10; recording the etiology, anatomical site and severity of illness will be the key to reaching the highest specificity that is appropriate for a patient’s condition. Clear and concise documentation will support the medical necessity for a service done on all encounters. Remember the saying, “If it is not documented, it was not done.”
For more information on coding and billing, contact Melesia Tillman, CPC, CPC-I, CHRC, CHA, at 404-633-3777 x820 or at firstname.lastname@example.org.