tci E/M Coding Alert - 2023 Issue Q3

Reader Questions: Explore Carpal Tunnel Coding from Beginning to End

Question: After a level-three evaluation and management (E/M) service for an established patient, the surgeon diagnoses carpal tunnel syndrome and performs a therapeutic injection. How should I report this encounter? Iowa Subscriber Answer: For this encounter, you should report the injection, an E/M, and a drug supply code (more on that later). So, on your claim, report: 20526 (Injection, therapeutic (eg, local anesthetic, corticosteroid), carpal tunnel) for the injection; Modifier LT (Left side) or RT (Right side) appended to 20526 to indicate laterality; 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which...

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