ICD 10 Coding Alert

Question: Encounter notes indicate that the provider performed a level-five office evaluation and management (E/M) service for an established patient suffering from nontraumatic intracerebral hemorrhage. How should I report this encounter?

Michigan Subscriber

Answer: The diagnosis code you choose for this 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.) encounter will depend on the “geography” of the hemorrhage (or hemorrhages).

Go back and check the notes. Then, choose from one of the following diagnosis codes:

• I61.0 (Nontraumatic intracerebral hemorrhage in hemisphere, subcortical)
• I61.1 (Nontraumatic intracerebral hemorrhage in hemisphere, cortical)
• I61.2 (Nontraumatic intracerebral hemorrhage in hemisphere, unspecified)
• I61.3 (Nontraumatic intracerebral hemorrhage in brain stem)
• I61.4 (Nontraumatic intracerebral hemorrhage in cerebellum)
• I61.5 (Nontraumatic intracerebral hemorrhage, intraventricular)
• I61.6 (Nontraumatic intracerebral hemorrhage, multiple localized)
• I61.8 (Other nontraumatic intracerebral hemorrhage)
• I61.9 (Nontraumatic intracerebral hemorrhage, unspecified).