Pulmonology Coding Alert

What evaluation and management (E/M) code should I assign for this visit?

Arkansas Subscriber

Answer: You’ll assign 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.) to report the E/M visit with this patient.

The CPT^® guidelines for office or other outpatient E/M services instruct you to select the appropriate code based on:

• Level of medical decision making (MDM) as defined for each service; or
• Total time for E/M services performed on the date of the encounter.

Whether you code by time or level of MDM, you’ll still assign 99213 for this encounter. Based on the information you provided, the physician met two of the three elements for a low level of MDM, and the physician met with the patient for 22 minutes.

During the encounter, the physician ordered chest X-rays and a lung function test. If your practice performed and billed both tests, they do not qualify for the Category 1: Tests and documents element of medical decision making (MDM), according to the CPT^® guidelines. This is because if the tests are ordered by someone from the same physician group (same specialty) and interpreted and billed by someone from the same physician group and specialty, you cannot give MDM credit for the order or review of the report.

However, the physician diagnosed the patient with an “acute, uncomplicated illness” to meet the low complexity requirements of the number and complexity of problems addressed at the encounter. Although the prescription qualifies as moderate risk, there is no other MDM element that qualifies for moderate complexity. Therefore, 99213 is appropriate.

Remember: Use caution when documenting time. Time should only include “activities” performed during the visit that are not separately billable. The physician needs to write the exact time in their documentation to ensure proper E/M coding. The time recorded needs to reflect the “total time spent on the date of the encounter,” according to the E/M guidelines in the CPT^® code set. For this patient encounter, a statement that this “time excludes the CXR and lung function testing” would be prudent if these two tests were also being billed in addition to the E/M service that day.

Additionally, you can assign R06.02 (Shortness of breath) to report the diagnosis.