Orthopedic Coding Alert

Question: Our orthopedist performed a level-three E/M service on a new patient last week. The visit lasted 45 minutes, yet CPT estimates the physician would spend only 30 minutes of face-to-face time with the patient for a level-three new patient E/M service. Can I append modifier -21 to the E/M code to account for the extra time?

Kansas Subscriber

Answer: You cannot append modifier -21 (Prolonged evaluation and management services) to a level-three E/M service.
 
In your case, you should simply report 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a detailed history, a detailed examination, medical decision-making of low complexity) for your E/M.
 
You should use modifier -21 only for "the highest level of evaluation and management service," according to CPT, meaning that you can only use it in conjunction with 99205 for a new patient outpatient visit.
 
Although the prolonged service codes (99354-99355) can be used with any E/M code, they would not apply in this scenario, because the time that your physician spent with the patient was not sufficient to warrant one of these add-on codes.

 - You Be the Coder and Reader Questions were reviewed by Heidi Stout, CPC, CCS-P, coding and reimbursement manager at UMDNJ-RWJ University Orthopaedic Group in New Brunswick, N.J.