Neurosurgery Coding Alert

Question: A new patient reports to the surgeon complaining of intermittent headaches that have been getting more severe; the headaches began after the patient hit their head after a fall from their bicycle that did not include any other people or vehicles (they just lost their balance and fell). After an office evaluation and management (E/M) service that included moderate-level medical decision making (MDM), the provider orders a complete skull X-ray. The results reveal a parietal skull fracture. How should I report this encounter?

Tennessee Subscriber

Answer: On this claim, report:

• 70260 (Radiologic examination, skull; complete, minimum of 4 views) for the X-ray
• 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.) for the E/M
• S02.0XXA (Fracture of vault of skull, initial encounter for closed fracture) appended to 70260 and 99204 to represent the patient’s skull fracture.
• V18.0XXA (Pedal cycle driver injured in noncollision transport accident in nontraffic accident, initial encounter) appended to 70260 and 99204 to represent the activity the patient was engaged in when the injury occurred.