May 21, 2015

Question:
I am new to orthopaedic coding, having just left a Family Practice group after many years. The surgeon said he did an injection to the flexor tendon sheath of the right index finger. I want to verify that CPT code 96372 is correct for the injection. I am very familiar with reporting the J codes for the drugs.

Answer:
Welcome to the world of Orthopaedic Coding! Your question is one that we receive on occasion when someone like yourself has taken the huge leap from the world of a medical practice into surgical coding. You will now want to familiarize yourself with the musculoskeletal section of the CPT book.

In the musculoskeletal section, find the section titled Introduction or Removal (20500-20697). You will see a list of codes beginning with CPT code 20500 through 20612 which will cover the majority of injections performed in a general orthopaedic practice. You state the injection was given to the flexor tendon sheath, thus the correct code will be 20550, Injection(s); single tendon sheath, or ligament, aponeurosis (e.g., plantar “fascia”). Kudos to the surgeon for the great documentation of exactly where the injection was administered. The appropriate J code may be reported in addition to CPT code 20550, as you are familiar with doing.

You may find it beneficial to set up a contract with KZA and work with Mary LeGrand on any of your coding or practice management needs. This relationship can be developed remotely and allow you access to Mary for any coding questions, assistance with operative notes, appeals, or audits. You may also consider attending an AAOS sponsored coding course.