Question: An established patient presents to the office complaining of pain in their right foot and toes, and pain in their left foot. The provider orders X-rays for both feet (3 views of the right foot, 2 views of the left foot). There is no indication of serious injury on the X-rays, so the physician recommends the patient take over-the-counter pain medication and rest their feet. Notes indicate that outside of the X-ray work, the provider performed an evaluation and management (E/M) service that involved low-level medical decision making (MDM). How should I code this encounter? Minnesota Subscriber Answer: On the claim, you’ll need to report the E/M, which as the notes indicate was deemed low-level for MDM, which translates to 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter.) Next, you will need to report the pain in the right and left feet in relation to the E/M visit: Last, you will need to report the X-rays and amend the pain codes to each: