Neurology & Pain Management Coding Alert

Question: Encounter notes indicate the provider performed an office evaluation and management (E/M) service that lasted 34 minutes, during which the provider performed low-complexity medical decision making (MDM). Final diagnosis was “centronuc. Myopathy, autosomal.” How should I code this encounter?

Illinois Subscriber

Answer: First, we’ll address the E/M coding; then we’ll look at reporting the diagnosis.

E/M: Go back to the notes and check if the patient is new or established. Then, choose one of the following codes, depending on patient status:

• 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 30-44 minutes of total time is spent on the date of the encounter.) if the patient was new
• 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.) if the patient was established

Explanation: Since you can code based on time or MDM level, you should choose the most beneficial code for your bottom line. This means that whether you coded this visit by time or MDM for a new patient, you would have to choose 99203. If the patient is established, however, you could choose 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.) if coding by MDM, or 99214 if coding by time.

Dx coding: Your provider’s shorthand diagnosis translates to autosomal centronuclear myopathy, which you’d report with G71.228 (Other centronuclear myopathy). This ICD-10 code could also be used for the following conditions:

• Autosomal dominant centronuclear myopathy
• Autosomal recessive centronuclear myopathy
• Centronuclear myopathy, NOS.