EM Coding Alert

Question: Our neurologist saw a 16 year-old patient with an established diagnosis of syncope that our physician originally diagnosed a year ago. The patient requires a release so he can get a driver’s license. The patient is doing well, and the doctor didn’t review or order any further testing. He also addressed a concussion that the patient mentioned during the history portion of the exam. The patient told the doctor that a sports medicine physician diagnosed the concussion four weeks ago and he is being followed by that physician for the condition. My neurologist signed the release forms for driving and wants me to charge a 99214, but as a coder I only see documentation for 99213. My doctor says that obviously, this is a high-risk visit that warrants 99214. Can you advise?

Codify Forum

Answer: You are correct. Although certifying this patient to drive, considering his history, does sound like a high-risk visit, if your documentation doesn’t support the 99214, then you have no choice but to report the lower level code.

The only way you could report a 99214, in absence of the appropriate key element documentation, would be if you qualify to bill based on time. This would require you to have spent 25 minutes with the patient, at least half of which involved counseling or coordinating care. This would have to be documented in the record. For instance, “I saw the patient for 30 minutes, and spent 25 minutes advising him of safe driving techniques and the warning signs of a syncopal event so he knows when it’s unsafe to drive.”

Based on the information provided, this visit should be coded with 99213.