EM Coding Alert

Question: How should I code this follow-up visit? A patient returned to our pediatrician after injuring her left shoulder. Our Encounter notes indicate that the provider performed an evaluation and management (E/M) service for an established 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?

Connecticut 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 time for code selection, 30-39 minutes of total time is spent on the date of the encounter.) for the E/M, using the moderate MDM as the marker for your code choice.

If you use time as the marker, you’d have to choose the lower-paying (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 time for code selection, 20-29 minutes of total time is spent on the date of the encounter.).

Dx coding: For the patient’s injury, append M80.071- (Age-related osteoporosis with current pathological fracture, right ankle and foot) to 99214 — after you choose one of these seventh-character options for M80.071:

• A: Initial subsequent encounter for fracture
• D: Subsequent encounter for fracture with routine healing
• G: Subsequent encounter for fracture with delayed healing
• K: Subsequent encounter for fracture with nonunion
• P: Subsequent encounter for fracture with malunion S: Sequela.