EM Coding Alert

Question: Encounter notes indicate that the provider performed an office evaluation and management (E/M) service that lasted 33 minutes and included low-complexity medical decision making (MDM). Final diagnosis was “constricted hip joint.” What is the best coding strategy for this encounter?

Arizona Subscriber

Answer: We’ll code the E/M first, and then the diagnosis. For the E/M you need to know if the patient was new or established. 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.)

If they were established, 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.)

Explanation: Given the description of the E/M, it qualifies for 99203 for a new patient because MDM and time are both consistent with this code. Conversely, you can code by time with 99214 and use the 33-minute encounter time as the basis for your code choice — even though the provider did not reach moderate MDM. (Remember, you only need to satisfy time or MDM on E/M code choice, not both.)

ICD-10 code: The description of the patient’s condition points to hip contracture, which ICD-10 describes as “connective tissue (tendon, muscle, ligament) that becomes stiff or constricted.” For this patient, you’ll choose from the following diagnosis codes, depending on encounter specifics:

• M24.551 (Contracture, right hip)
• M24.552 (Contracture, left hip)
• M24.559 (Contracture, unspecified hip).