“An established patient returns to the clinic with new right foot pain. I palpated a mass that had the characteristics of a ganglion cyst and ordered an MRI for evaluation. The patient is leaving on vacation and asked me to do something. I offered him to aspirate and inject it with a steroid. The patient agreed with the plan. I would like to code:
E/M code 99213 since I wrote a prescription for an MRI
CPT code 20612 for ganglion cyst injection
Can I bill the E/M because I sent a prescription and billed an injection at the same time?”
So, an established patient returns to the clinic with a new problem that has not been addressed previously. How is a new problem defined? A new problem is one that has never been mentioned, never been examined, never been treated. The patient has pain in the right foot. Upon physical examination, it appears that the patient has a ganglion cyst. It was decided upon by the physician after a discussion with the patient that an MRI would be ordered to identify, diagnosis and confirm that what is present is indeed a ganglion cyst. A medically appropriate history and/or a medically appropriate examination along with the fact that the ordering of the MRI (“Low risk of morbidity from additional diagnostic testing or treatment”) to evaluate this “acute, uncomplicated illness or injury” generates medical decision making of low complexity. This supports the billing of E/M code 99213.
Since the patient is going on vacation, it was decided upon by the physician after a discussion with the patient to administer a cortisone injection and aspirate what appears to be a ganglion cyst. This would be coded with CPT code 20612 which is defined as the following: Aspiration and/or injection of ganglion cyst(s) any location.
Based upon the above post and the documentation within the medical record, I would find it appropriate to append the 25 modifier to E/M code 99213 to designate a significant and separately identifiable E/M service. The E/M service is for the diagnosis/identification of the presenting problem. The CPT/procedure code is for the treatment of the acute presenting symptoms.
The coding scenario would be the following:
CPT 99213 – 25 (M67.471- Ganglion, right ankle and foot or M67.472-Ganglion, left ankle and foot)
CPT 20612 – RT or LT (M67.471- Ganglion, right ankle and foot or M67.472-Ganglion, left ankle and foot)
This is my opinion.
Michael G. Warshaw, DPM, CPC
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