Internal Medicine Coding Alert

Question: An established patient undergoes a continuous glucose monitoring system (CGMS) insertion on Monday. During the encounter, the internist performs a detailed exam and history, and medical decision-making of moderate complexity related to the patient's diabetes, hypertension and coronary artery disease. The internist then instructs the patient on how to use the device properly. Three days later, the patient returns to the office, and one of our nurses disconnects the device and downloads the data. The internist did not perform the CGMS test interpretation and report. How should I code this encounter?

Missouri Subscriber

Answer: You'll report an E/M for the first encounter, and the CGMS code for the second encounter.

First encounter: If the patient had reported to the internist solely for the CGMS insertion, you would not be able to report any codes for this meeting. However, because your internist provided a significant and separately identifiable service on that day (history, exam, moderate medical decision-making) in addition to the insertion, you should report an E/M code for the service.

According to your description, the internist provided a level-four E/M. On the claim, report 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a detailed history; a detailed examination; medical decision making of moderate complexity).

Second encounter: The date the patient returns for removal should mark your CGMS procedure code. Report the encounter with 95250 (Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for up to 72 hours; sensor placement, hook-up, calibration of monitor, patient training, removal of sensor, and printout of recording).

Third encounter: Remember, if the patient returns to review the data with the internist on another day, you can code it as an E/M service.