Neurosurgery Coding Alert

Question: Encounter notes indicate that the surgeon performed an evaluation and management (E/M) service on an established patient with meningitis caused by E. coli poisoning. Total encounter time was 49 minutes. What is the correct coding for this encounter?

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Answer: Coding for the E/M is easy; the diagnosis, however, is a bit tricky.

First, you’ll report 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 total time on the date of the encounter for code selection, 40 minutes must be met or exceeded.) for the E/M.

Then, append G00.8 (Other bacterial meningitis) to 99215 to represent the patient’s meningitis. Finally, you’ll report one of the following codes to represent the specific type of E. coli bacteria that caused the infection:

• B96.20 (Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere)
• B96.21 (Shiga toxin-producing Escherichia coli [E. coli] [STEC] O157 as the cause of diseases classified elsewhere)
• B96.22 (Other specified Shiga toxin-producing Escherichia coli [E. coli] [STEC] as the cause of diseases classified elsewhere)
• B96.23 (Unspecified Shiga toxin-producing Escherichia coli [E. coli] [STEC] as the cause of diseases classified elsewhere)
• B96.29 (Other Escherichia coli [E. coli] as the cause of diseases classified elsewhere).