Revenue Cycle Insider

Question: Encounter notes indicate that the neurosurgeon treated a new patient who had just suffered a head injury after colliding with a street sign on a skateboard the day before. The surgeon performed an evaluation and management (E/M) service to ask the patient about how the injury happened, their symptoms, and time elapsed since the accident. The surgeon also tested the patient’s coordination, reflexes, memory, and concentration. Encounter notes indicate that the surgeon performed moderate medical decision making (MDM) during the E/M. They then ordered a computed tomography (CT) scan without contrast material, which confirmed the presence of a diffuse traumatic brain injury (TBI) without loss of consciousness. The practice owns the CT equipment. How should I report this encounter?

Maryland Subscriber

Answer: You’ll be able to code for the CT and the E/M — if you include the proper modifier.

On your claim, report

• 70450(Computed tomography, head or brain; without contrast material) for the CT
• 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded.) for the E/M
• Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) appended to 99204 to show that the CT and E/M were significant, separately identifiable services
• S06.2X0A (Diffuse traumatic brain injury without loss of consciousness, initial encounter) appended to 70450 and 99204 to represent the patient’s TBI
• V00.132A (Skateboarder colliding with stationary object, initial encounter) appended to 70450 and 99204 to represent the cause of the patient’s TBI.

Chris Boucher, MS, CPC, Senior Development Editor, AAPC