Neurology & Pain Management Coding Alert

Question: An established patient presented to the practice complaining of intense headaches, blurred vision, and nausea after falling in the snow and hitting their head. The provider conducted a concussion questionnaire with the patient and performed an appropriate history and examination. Fearing concussion, the provider ordered a computed tomography (CT) scan, first without contrast then with contrast and further sections. Results of the scan confirmed concussion. Notes indicate that the provider performed high-level medical decision making (MDM) during the evaluation and management (E/M) service, informing the need for the CT scan. How should I code this encounter?

Wyoming Subscriber

Answer: The CPT^® coding is straightforward enough. Your ICD-10 code choice, however, could be better focused with some more information about the patient and their injury.

CPT^® coding: On the claim, 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 and 70470 (Computed tomography, head or brain; without contrast material, followed by contrast material(s) and further sections) for the CT scan.

ICD-10 coding: You’re best served rechecking the notes before choosing diagnosis codes for this patient, as more information could lead to a more detailed and descriptive ICD-10 code. When you’re checking the notes, ask yourself these questions:

• Did the patient lose consciousness?
• If the patient lost consciousness, how long did it last?
• Did the patient fall off steps or stairs?
• Did the patient fall from one level to another?

Then, you’ll choose the most appropriate codes from each of these lists (one code per list):

Concussion

• S06.0X0A (Concussion without loss of consciousness, initial encounter)
• S06.0X1A (Concussion with loss of consciousness of 30 minutes or less, initial encounter)
• S06.0XAA (Concussion with loss of consciousness status unknown, initial encounter)
• S06.0X9A (Concussion with loss of consciousness of unspecified duration, initial encounter)

Fall

• W00.0XXA (Fall on same level due to ice and snow, initial encounter)
• W00.1XXA (Fall from stairs and steps due to ice and snow, initial encounter)
• W00.2XXA (Other fall from one level to another due to ice and snow, initial encounter)
• W00.9XXA (Unspecified fall due to ice and snow, initial encounter)

Final word: Once you’ve settled on ICD-10 codes for this encounter, append both of them to 99215 and 70470 to represent the patient’s condition and the cause of the injury, respectively.