HIS Coding Update

Medical Coding

E/M Documentation Changes 2021

Visco-supplement Code Changes

Coding Tip- Spine Radiofrequency

IDC-10 2021 Update

Lynn M. Anderanin, CPC, CPMA, CPC-I, CPPM, COSC

E/M Documentation Changes 2021

The new documentation guidelines for office and outpatient visits go into

effect on January 1, 2021. The level of service will now be determined by

new guidelines, and you will have the choice of time or medical decision

making. These changes will be in effect for all insurance carriers and will be

published in CPT 2021. Please contact me with any questions or concerns

regarding these changes.

Visco-supplement Code Changes

Two code changes for visco-supplement became effective on July 1, 2020.

  • J7321- Hyalgan or Supartz, per dose- revised
  • J7333- Visco-3, per dose- added

Spine Radiofrequency

There has been some confusion regarding the CPT code 64625 that became

effective on January 1, 2020, and other codes. 64625 is to be used for

radiofrequency ablation of nerves innervating the SI joint. 63635 is for

The destruction of paravertebral facet joint nerve(s) and is reported per facet joint.

For denervation of the facet joint using the thermal energy of <80 degrees

Celsius, or pulsed radiofrequency, this should be reported as 64999.

ICD-10-Update 2021

The ICD-10 updates become effective on October 1, 2020. There are

changes to include rheumatoid arthritis and osteoporosis. The new codes for

musculoskeletal are as follows:

  • M05.7A Rheumatoid arthritis with rheumatoid factor of other specified sites without organ or systems involvement 
  • M05.8A Other rheumatoid arthritis with a rheumatoid factor other specified sites 
  • M06.0A Rheumatoid arthritis without rheumatoid factor, other specified sites 
  • M06.8A Other specified rheumatoid arthritis, other specified sites 
  • M08.0A Unspecified juvenile rheumatoid arthritis, other specified sites 
  • M08.2A Juvenile rheumatoid arthritis with systemic onset, other specified sites 
  • M08.4A Pauciarticular juvenile rheumatoid arthritis, other specified sites 
  • M08.9A Juvenile arthritis, unspecified, other specified sites • M19.09 Primary osteoarthritis, other specified sites 
  • M19.19 Post-traumatic osteoarthritis, other specified sites 
  • M19.29 Secondary osteoarthritis, other specified sites 
  • M24.19 Other articular cartilage disorders, other specified sites 
  • M24.29 Disorder of ligament, other specified sites 
  • M24.39 Pathological dislocation of other specified joint, not elsewhere classified 
  • M24.49 Recurrent dislocation, other specified joint 
  • M24.59 Contracture, other specified joint 
  • M24.69 Ankylosis, other specified joint 
  • M24.89 Other specified joint derangement of other specified joints, not elsewhere classified 
  • M25.39 Other instability, other specified joint 
  • M25.59 Pain in other specified joint 
  • M25.69 Stiffness of other specified joints, not elsewhere classified 
  • M80.0 Age-related osteoporosis with current pathological fracture 
  • M80.0A- other sites 
  • M80.0AXA- initial encounter 
  • M80.0AXD- subsequent encounter, routine healing 
  • M80.0AXG- subsequent encounter, delayed healing 
  • M80.0AXK- subsequent encounter, nonunion 
  • M80.0AXP- subsequent encounter, malunion 
  • M80.0AXS- sequela 
  • M80.8 Other osteoporosis with current pathological fracture 
  • M80.8AXA- initial encounter 
  • M80.8AXD- subsequent encounter, routine healing 
  • M80.8AXG- subsequent encounter, delayed healing 
  • M80.8AXK- subsequent encounter, nonunion 
  • M80.8AXP- subsequent encounter, malunion 
  • M80.8AXS- sequela 
  • M92.50 Juvenile osteochondrosis of tibia and fibula 
  • M92.501- right 
  • M92.502- left 
  • M92.503- bilateral 
  • M92.51 Juvenile osteochondrosis of the proximal tibia 
  • M92.511- right 
  • M92.512- left 
  • M92.513- bilateral 
  • M92.52 Juvenile osteochondrosis tibial tubercle 
  • M92.521- right 
  • M92.522- left 
  • M92.523- bilateral 
  • M92.59 Other juvenile osteochondrosis of the tibia and fibula 
  • M92.591- right 
  • M92.592- left 
  • M92.593- bilateral