Don’t Upcode This Low-Level Follow-Up
Question: I’m coding a follow-up encounter for a patient who experienced a neck injury during a soccer game. The provider reviewed the patient’s MRI scan results, ordered physical therapy, and prescribed a refill of an anti-inflammatory drug. Can I report 99214? Texas Subscriber Answer: The encounter you describe may not meet the criteria needed to be able to report evaluation and management (E/M) service code 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate 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.) for a couple of reasons. The injury itself may be a single acute and uncomplicated injury, which means you have few problems addressed during this encounter. You don’t mention whether the provider changed the dosage of the anti-inflammatory; if not, then the prescription management services provided probably do not rise to the moderate level of risk. With the information you’ve provided, it sounds like the MRI reading would count toward the date of service (DOS) when it was originally ordered — not for the follow-up visit. With this information in mind, it’s probably better to report 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 total time on the date of the encounter for code selection, 20 minutes must be met or exceeded.). Rachel Dorrell, MA, MS, CPC-A, CPPM, Development Editor, AAPC
