EM Coding Alert

Question: Notes indicate the provider performed an office evaluation and management (E/M) service that included moderate medical decision making (MDM) and took 43 minutes. Then, the provider performed a computed tomographic (CT) angiography on the patient. What is the correct coding for this encounter?

West Virginia Subscriber

Answer: Before you code this encounter, you’ll need to go back to the notes (or the provider) and ask these questions:

Is the patient new or established?

In what anatomical area is the provider performing the CT angiography?

E/M code: If the patient was new, you’d report 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is spent on the date of the encounter.) applying MDM as the deciding factor in this E/M code selection, as using time would result in a lower-level code.

If the patient was established, choose 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.) applying time as the deciding factor in this E/M code selection, as using MDM would result in a lower-level code.

CT coding: For the CT angiography code, check the notes (or talk to the provider) to see if the provider performed the CT angiography on the patient’s head or neck.

If the CT angiography was on the patient’s head, report 70496 (Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if performed, and image postprocessing).

If the CT was on the patient’s neck, report 70498 (Computed tomographic angiography, neck, with contrast material(s), including noncontrast images, if performed, and image postprocessing).

Remember to apply modifier 26 (Professional component) if only the professional supervision and interpretation component of the CT angiogram is performed.