EM Coding Alert

Question: I have a provider that saw a patient on Monday and coded a 99214. He then saw the same patient the next day for a follow up and coded a 99213 and 10060. Is this correct coding or should the E/M for the follow-up visit be a 99212?

New Mexico Subscriber

Answer: Code 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 …) or 99213 (…which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity …) could be correct. Office encounter coding is based on the documented levels of history, examination, and medical decision making. The patient is established so you’ll choose a code in the 99212-99215 series, based on those key elements. The fact that the encounter was a follow-up visit has not direct bearing on the code choice.

Pointer: Since you’ll be reporting 10060 (Incision and drainage of abscess [eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia]; simple or single) along with the second day’s E/M code, you’ll need to attach modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the E/M code to show your payer that the E/M visit and the incision and drainage procedure were separate procedures. Ensure the physician provided a separately identifiable E/M service before you report both codes. If he only did a pre-procedure evaluation, you should only report 10060.

In your situation, it should be extremely clear why the E/M on the second day should be billed. If the decision to do the I & D was made the first day, the second visit wouldn’t be billable. Additionally, if a brief visit was performed around the area of concern, then there too, the E/M would not be billable on that second day. Work with your provider to make certain the documentation clearly illustrates the need for that visit.