Neurosurgery Coding Alert

Question: Encounter notes indicate that the provider performed an office evaluation and management (E/M) service for a patient who had a diagnosis of concussion. Total encounter time was 33 minutes and the provider performed moderate medical decision making (MDM). How should I report this encounter?

Iowa Subscriber

Answer: This note is incomplete and uncodable without more info.

You’re going to need a few more elements from the notes to determine the appropriate codes. Go back and check the notes — or check with the provider — to try to obtain these pieces of information:

1. Was the patient new or established?
2. Did the patient lose consciousness during the concussion?
3. If yes to question 2, how long did the patient lose consciousness?
4. What stage of visit is this E/M: initial, subsequent, or sequela?

E/M coding: If the patient was new, code based on the MDM level and choose 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 time for code selection, 45-59 minutes of total time is spent on the date of the encounter.). If the patient was established, code based on the total encounter time and choose 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.).

ICD-10 coding, step 1: Once you’ve got answers to questions 2 and 3, you’ll be able to narrow down your concussion diagnosis code choices to:

• S06.0X0- (Concussion without loss of consciousness)
• S06.0X1- (Concussion with loss of consciousness of 30 minutes or less)
• S06.0X9- (Concussion with loss of consciousness of unspecified duration)
• S06.0XA- (Concussion with loss of consciousness status unknown)

ICD-10 coding, step 2: You’ll also need a 7th character for the concussion diagnosis code. Choose one of the following 7th characters, depending on encounter specifics:

• A = initial encounter
• D = subsequent encounter
• S = sequela.