General Surgery Coding Alert

Question: I have a procedure note indicating that the provider performed an outpatient evaluation and management (E/M) service for an established patient. The physician documented a total encounter time of 46 minutes, and also documented performing moderate medical decision making (MDM). How should I code this?

Georgia Subscriber

Answer: You should 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 service.

Based on the 2021 changes to office/ outpatient E/M code descriptors, you can use time or MDM as the sole factor when determining E/M level. Since encounter time puts you in the 99215 bracket, you should opt for this code.

Technically, you wouldn’t be wrong to use 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.), since the MDM was moderate for the encounter. This coding is not optimal, however, as you could just as rightly report the higher-paying 99215.