Neurosurgery Coding Alert

Question: Notes indicate that the provider performed an office evaluation and management (E/M) service for an established patient. Final diagnosis was concussion. During the encounter, the provider performed moderate-level medical decision making (MDM), but the visit lasted 27 minutes. How should I report this encounter?

Massachusetts Subscriber

Answer: Provided the notes support that the physician performed moderate-level MDM, you should 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.) for the service.

Why? With the new coding rules for 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter.) through 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.), you only need to satisfy the MDM or the time requirement for each office/outpatient E/M code. Since using MDM to determine level is the most beneficial toward your practice, you should go by MDM when selecting this E/M.

You could report 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.), but it’s not the optimal code for this service because the higher-paying 99214 is also an option.

Diagnosis coding: You need to go back and check the notes for any potential loss of consciousness during the patient’s concussion-inducing event. Then, you’ll choose from the following ICD-10 codes:

• S06.0X0A (Concussion without loss of consciousness, initial encounter)
• S06.0X1A (Concussion with loss of consciousness of 30 minutes or less, initial encounter)
• S06.0X9A (Concussion with loss of consciousness of unspecified duration, initial encounter).