Question: Encounter notes indicate that the provider performed an office evaluation and management (E/M) service for an established patient with ‘CRPS 1 arm.’ Total encounter time was 27 minutes and involved low-level medical decision making (MDM). How should I report this encounter? Arkansas Subscriber Answer: Your CPT® coding answer is easy enough; report 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter.) for the E/M service. The ICD-10 code you choose isn’t as clear, however. Your notes, indicative of complex regional pain syndrome 1 (CRPS I) can get you to G90.51- (Complex regional pain syndrome I of upper limb). If you want the most complete ICD-10 code, however, you can’t stop there. Do this: Go back and check the notes to see if the provider indicated laterality for the CRPS. Then, choose one of the following ICD-10 codes: Last resort: If you can’t get more information, append G90.519 (Complex regional pain syndrome I of unspecified upper limb) to 99213.