code to used

Hi, I have here the scenario:

44 year old female presents with c/o Knee for more than 2 years bilateral left knee more than the right, anteriorly, medial joint line, Severity: severe Onset: gradual, Aggravated by: any physical activity, improved with cortisone injections and aleve daily., locks and unable to flex knee completely..

Assestment:
1. Other specified arthropathy, lower leg - 716.86 (Primary)
2. Cervical spondylosis with myelopathy - 721.1
3. Impaired fasting glucose - 790.21

Can I used 99214 e/m code
20610
J3301-- at the same time?

thanks in advance,,

rhina

re: code to used

You can bill an E/M service if this is the first assessment. We can't tell what level of service from what you've written.

There are articles and discussions about the topic on Codapedia.

http://codapedia.com/article_206_Modifier-25.cfm

http://codapedia.com/article_207_Can-we-bil-a-low-level-E-M-with-every-procedure.cfm

re: code to used

Of course it is necessary to review the note and components of the E/M service. If an injection was given and documented, it is appropriate to code the joint injection and the J code for solution. If E/M was documented and medically necessary, add modifier -25 to E/M code.
The diagnosis codes would be assigned on why the patient came to office today and any associated conditions that may impact on patient's management that day.