General Surgery Coding Alert

Question: Our surgeon wants to use the digital E/M codes, but we’re having difficulty documenting the time over multiple days. How can we document and bill these codes?

Utah Subscriber

Answer: The online digital evaluation and management (E/M) codes for physicians are the following:

• 99421 (Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes)
• 99422 (… 11-20 minutes)
• 99423 (… 21 or more minutes)

As you describe, keeping track of this service so that you can bill it is difficult, because the work occurs over a seven-day period.

Tip: You could have your surgeon submit a bill with a specific, agreed-upon unbillable procedure code each time they perform a digital service, even if it does not meet the time threshold. The coder could then gather the information from each date to see if the service meets a billable threshold over a seven day time period.

Bottom line: You should work with your compliance officer to establish any form of documentation that captures the work each day and allows the surgeon to certify and submit the work for billing.