Neurology & Pain Management Coding Alert

Question: The provider performed an office evaluation and management (E/M) service for an established patient with “oxycephaly.” Encounter notes indicate that the provider performed moderate-level medical decision making (MDM). How do I choose a diagnosis code for this encounter? I think that the code would be in the Q75.- (Other congenital malformations of skull and face bones) set somewhere, but I can’t seem to find it.

Arkansas Subscriber

Answer: You’ll append Q75.0 (Craniosynostosis) to 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter.) for this encounter. Oxycephaly is an alternate term for craniosynostosis.

More info: You’ll find a lot of alternate terms listed under the diagnosis codes in the Q75.- code set. Here is a list of the codes in the group and a list of the code’s synonyms, where applicable:

• Q75.0

o Acrocephaly

o Imperfect fusion of skull

o Oxycephaly

o Trigonocephaly

• Q75.1 (Craniofacial dysostosis)

o Crouzon’s disease

• Q75.2 (Hypertelorism)
• Q75.3 (Macrocephaly)
• Q75.4 (Mandibulofacial dysostosis)

o Franceschetti syndrome

o Treacher Collins syndrome

• Q75.5 (Oculomandibular dysostosis)
• Q75.8 (Other specified congenital malformations of skull and face bones)

o Absence of skull bone, congenital

o Congenital deformity of forehead

o Platybasia

• Q75.9 (Congenital malformation of skull and face bones, unspecified)

o Congenital anomaly of face bones NOS

o Congenital anomaly of skull NOS