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Pain Management Coding Alert

You Be the Coder:

Try Coding This E/M + X-ray Scenario

Question: An established patient reports to the PM specialist complaining of severe rib pain in his left flank; this is the initial encounter for this injury. After a level-two evaluation and management (E/M) service the provider decides to take a two-view unilateral X-ray, which confirms a pair of left-sided rib fractures. (We use our own X-ray equipment). What is the correct coding for this encounter?

Florida Subscriber

Answer: For this claim, you’ll be able to report a pair of codes with the same ICD-10 code appended to each.

On the claim, report:

  • 71100 (Radiologic examination, ribs, unilateral; 2 views) for the X-ray
  • 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making …) for the E/M service
  • S22.42-A (Multiple fractures of ribs, left side, initial encounter) appended to 71100 and 99212 to represent the patient’s injuries.

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