EM Coding Alert

Question: Notes indicate that the provider performed an office evaluation and management (E/M) service for a new patient that included low medical decision making (MDM) and lasted 27 minutes. Final diagnosis was carpal tunnel syndrome (CTS). How should I code this encounter?

Illinois Subscriber

Answer: First, you’ll opt for 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 30-44 minutes of total time is spent on the date of the encounter.) for the E/M. You’ll arrive at this code when you use MDM level (low) as the sole factor in determining E/M encounter level.

ICD-10 coding: For the most accurate diagnosis code, you’ll need to go back and check the notes. Then, choose from the following CTS ICD-10 codes:

• G56.00 (Carpal tunnel syndrome, unspecified upper limb)
• G56.01 (Carpal tunnel syndrome, right upper limb)
• G56.02 (Carpal tunnel syndrome, left upper limb)
• G56.03 (Carpal tunnel syndrome, bilateral upper limbs).