This patient encounter should be coded as 99214-25, 73721- LT, 20610-LT 76942-26.
Diagnoses: 714.0, 535.00, E943.8
The MRI of the knee was coded as 73721 because it was an MRI of the joint lower extremity. Code 73718 should not be used in this circumstance because that code is for the lower extremity other than the joint. Modifier -25 is used to indicate that the patient required a significant, separately identifiable evaluation and management (E/M) service on the same day she received a minor procedure. The E/M services that result in the decision to perform a procedure on the same day are considered to be part of the evaluation for the procedure and are not separately billable.
However, this patient had a separate problem, gastritis, which required E/M services, and therefore the portion of the encounter related to the diagnosis and treatment of the patient’s gastritis are separately billable with the use of modifier -25. The E/M services related to the patient’s gastric symptoms included:
- Expanded problem-focused history;
- Detailed exam; and
- Moderate-complexity decision making: treatment side effect—gastritis—requiring change in medication therapy and additional prescription medication to treat gastritis.