EM Coding Alert

Question: My physician’s notes indicate that they performed an office evaluation and management (E/M) service for an established 75-year-old patient that lasted 29 minutes. The provider performed moderate medical decision making (MDM). Final diagnosis was “osteoporosis, R ankle, w/ path fracture.” What is the correct coding for this encounter?

Utah Subscriber

Answer: You should report 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded) for the E/M, using the moderate MDM as the marker for your code choice.

Why? If you only use time to determine the E/M level, you’d have to choose the less compensated (but still correct) 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded).

However, in this case, billing the E/M by MDM is a better option. That’s because, in this encounter, the physician diagnosed the patient with a single, acute injury that is complicated by the patient’s osteoporosis. This would rise to the moderate level of the number and complexity of problems addressed MDM element. Assuming the encounter also required the provider to consider multiple treatment options, review and analyze test results, or coordinate care with other healthcare professionals, the level of the amount and/or complexity of data to be reviewed and analyzed MDM element would also rise to the moderate level. This would give an overall MDM level of moderate for the encounter, as two of the three MDM elements have been satisfied at that level and allow you to bill 99214.

Dx coding: For the patient’s injury, you would use M80.071A (Age-related osteoporosis with current pathological fracture, right ankle and foot, initial encounter for fracture) appended to the claim line for 99214. You would choose the 7th character A (Initial encounter for fracture) because the patient is receiving active treatment for the fracture. This doesn’t necessarily mean it’s the patient’s first visit for the fracture; the 7th character A should be used for any visit where the patient is receiving active treatment such as surgery, emergency department (ED) encounter, or evaluation and treatment by a new physician. You would use the character to describe the entire period where the patient is receiving ongoing treatment for the fracture. The character helps to accurately document the patient’s medical record and ensures appropriate reimbursement for the healthcare services provided.