Neurology & Pain Management Coding Alert

Question: Encounter notes indicate that the physician performed an office evaluation and management (E/M) service for a new patient that lasted 52 minutes and included moderate-level medical decision making (MDM). Final diagnosis was “cerebellar abscess, embolic.” I don’t see an ICD-10 code for this condition. Can you help?

Florida Subscriber

Answer: The diagnosis code you’ll report is G06.0 (Intracranial abscess and granuloma). ICD-10 lists “cerebellar abscess (embolic)” as codeable with G06.0. Other terms that you might find on encounter notes that would be synonymous with a G06.0 diagnosis are:

• Brain [any part] abscess (embolic)
• Cerebral abscess (embolic)
• Intracranial epidural abscess or granuloma
• Intracranial extradural abscess or granuloma
• Intracranial subdural abscess or granuloma
• Otogenic abscess (embolic)

As for the E/M, you’ll 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.).

Even though the visit only featured moderate MDM — which would mean 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appro priate 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.) — the time of the encounter qualifies it for 99215.