Neurosurgery Coding Alert

Question: During an office evaluation and management (E/M) service for an established patient, the surgeon diagnoses Shy-Drager syndrome. The E/M included moderate-level medical decision making (MDM) and lasted 34 minutes. How should I report this encounter? I’m a little unclear on what Shy-Drager syndrome is, or how to choose a diagnosis code for the condition.

Nebraska Subscriber

Answer: First, the coding; then some diagnostic explanation.

On the claim, report:

• 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 the E/M.
• G90.3 (Multi-system degeneration of the autonomic nervous system) appended to 99214 to represent the patient’s Shy-Drager syndrome.

Shy-Drager explained: The reason you had trouble finding an ICD-10 code might have something to do with the term Shy-Drager syndrome, which is a bit dated. The current correct term for Shy-Drager syndrome is multiple system atrophy (MSA), which translates to G90.3. According to Mayo Clinic, this “is a rare, degenerative neurological disorder affecting your body’s involuntary (autonomic) functions, including blood pressure, and motor control. MSA was formerly called Shy-Drager syndrome, olivopontocerebellar atrophy, or striatonigral degeneration.”