EM Coding Alert
Select E/M Level Code, Go All-Out on Diagnosis
Question: Notes indicate the provider performed a level-four office evaluation and management (E/M) service for an established patient that lasted 42 minutes and included moderate medical decision making (MDM). Final diagnosis was “displ. Osteochon. Fx, L patella.” How should I report this encounter? New Hampshire Subscriber Answer: You’ll report 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.) for the E/M. Your choice for the ICD-10 code isn’t completely clear from the encounter description. You’ll report S82.012- (Displaced osteochondral fracture of left patella) for the patient’s injury — but don’t stop there. All diagnosis codes in category S82 (Fracture of lower leg, including ankle) require a 7th character. So go back and check the notes and choose one of these 7th character options to add to S82.012-: 
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