Question: Our practitioner saw a new patient for postnasal drip and difficulty breathing through their nose. The patient was a former heavy smoker but was able to quit several years ago. The office/outpatient evaluation and management (E/M) service lasted 41 minutes and involved low-level medical decision making (MDM). Following the exam, the provider ordered a computed tomography scan (CT) to confirm the diagnosis before deciding on the correct treatment. A different facility performed and interpreted the CT. The practitioner ended up diagnosing this patient with a nasopharyngeal polyp. How should I report this encounter?
Indiana Subscriber
Answer: You can use time to code the practitioner’s E/M service in this case. To do so, you would report 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.). If you choose not to use time for the encounter, you will still use 99203 to code the E/M service based on low-level MDM, as the patient presented with one uncomplicated problem, the practitioner ordered one test, and there was a very low risk of mortality in the patient's treatment.
Because the facility performing the CT scan will separately bill that service, you will not add this to your claim.
The primary diagnosis code for this case will be J33.0 (Polyp of nasal cavity). You should use this code if you see the term “choanal polyp” or “nasopharyngeal polyp” somewhere in the notes. Since the patient is a former smoker, you’ll also need to report Z87.891 (Personal history of nicotine dependence) on the claim.
Lindsey Bush, BA, MA, CPC, Development Editor, AAPC
