EM Coding Alert

You Be the Coder:

Look to Patient Status for Appropriate E/M Code

Published on Wed Jun 22, 2022

Question: Encounter notes indicate that the provider performed an office evaluation and management (E/M) service that included low-level medical decision making (MDM) and lasted 35 minutes. The patient had a diagnosis of “dyskinetic CP.” How should I report this encounter?

Michigan Subscriber

Answer: The E/M answer will depend on the patient’s status.

If they were new, report 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.

If they were established, choose 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.

Dx coding: Whether you choose 99203 or 99214, be sure to assign G80.3 (Athetoid cerebral palsy) as your diagnosis. The shorthand “dyskinetic CP” refers to dyskinetic cerebral palsy (CP). Dyskinetic CP is listed as a synonym for athetoid CP under the G80.3 descriptor.

CP breakdown: There’s more going on in the CP section of ICD-10 than you might think. Here’s a full list of the code family for G80.- (Cerebral palsy), along with synonyms for the main code descriptors: