The patient presented today with swelling and pain in the right knee. The patient suffers from primary osteoarthritis. Following an expanded problem-focused history and expanded problem-focused examination, the physician aspirated the joint and gave the patient an injection of steroid medication. Select the appropriate codes for today's visit:

Question

Quizplus · Accepted Answer

The correct codes are 99213-25, 20610, M17.11. Code 99213-25 represents an office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem-focused history; an expanded problem-focused examination; and medical decision making of low complexity. The modifier -25 indicates that a significant, separately identifiable evaluation and management service was performed by the same physician on the same day of the procedure. Code 20610 is for aspiration and/or injection of a major joint or bursa (e.g., shoulder, hip, knee joint, subacromial bursa). M17.11 is the ICD-10 code for primary osteoarthritis of the right knee, which is the specific condition being treated.

The Patient Presented Today with Swelling and Pain in the Right