Coding for SI Injections with Office Visit A female patient previously diagnosed with sacroiliitis and ankylosing spondylitis returns to the office for a follow-up visit. The patient reports her lower back has been stiff and swollen for the past couple of weeks. She is currently on celecoxib and ranitidine, and mentions that she had some…
Rheumatology Coding Corner Answer: Sacroiliac Injection with Office Visit
CPT codes: 99214-25, 27096, J3301 x1 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…