Neurosurgery Coding Alert

Reader Questions:

Note Differentials When Making E/M Level Decision

Published on Thu Jan 06, 2022

Question: An established patient came to our office complaining of left-sided facial pain that began two days earlier. Our provider documented multiple differentials and administered a dose of Decadron in the office. He advised the patient to monitor the symptoms over the next 24 hours. How should I calculate the level of medical decision making (MDM) for this encounter? Is this a level-three evaluation and management (E/M) service?

AAPC Forum Participant

Answer: Without seeing the details of your provider’s note, it is hard to determine MDM in this scenario precisely.

However, two things in this encounter suggest the MDM probably rises to level four and not level three, as you suggest.

First, your provider has described a diagnosis with multiple differentials that need to be evaluated. This may well meet the definition of an undiagnosed new problem with an uncertain prognosis, which more closely aligns with level four MDM, rather than an acute, uncomplicated illness or injury, which would be more associated with level three.

Second, your provider decided to administer a steroid — a prescription drug — in order to treat the patient’s condition. Prescription drug management is an example of a moderate level of risk of morbidity in the MDM table, which again suggests level four MDM.

So, you may well be able to justify billing office/outpatient E/M 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 …) for this encounter, though you would do well to discuss this further with your provider before doing so.