Coding Corner Answer: April Coding Challenge

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The correct way to bill this visit is:

99214-25, 27096, J3301 x1

Coding Corner Answer 720.2, 720.0

This encounter is coded as 99214 because it included:

• Detailed history;
• Comprehensive examination—eight systems reviewed; and
• Medical decision making—moderate complexity (established problem, new problem with no additional workup, new prescription drug ordered).

Note: The CT guidance is an inclusive component of the SI injection. The 2013 CPT code description for a SI injection is, “Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed.” It should be noted that if CT or fluoroscopy imaging is not performed, the code should be reported as 20552. Ultrasound guidance is not reportable with this code.