EM Coding Alert

Question: Notes indicate that the surgeon performed a level 4 office evaluation and management (E/M) service and a magnetic resonance imaging (MRI) of the brain without contrast, followed by contrast and further sequences, for an established patient. Final diagnosis was “embolic cerebellar abscess.” How should I report this encounter?

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Answer: On the claim, report:

• 70553 (Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material, followed by contrast material(s) and further sequences)) for the MRI,
• 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 the E/M, and
• G06.0 (Intracranial abscess and granuloma) appended to 70553 and 99214 to represent the patient’s cerebellar abscess.

More on abscesses/granulomas: As you see in the answer to your question, there are synonyms for “intracranial abscess and granuloma” that you would also code to G06.0.

Here is the full list of alternate terms for G06.0:

• Brain [any part] abscess (embolic)
• Cerebellar abscess (embolic)
• Cerebral abscess (embolic)
• Intracranial epidural abscess or granuloma
• Intracranial extradural abscess or granuloma
• Intracranial subdural abscess or granuloma
• Otogenic abscess (embolic)

Check out spinal abscesses/granulomas: There is also a code for spinal abscess or granuloma: G06.1 (Intraspinal abscess and granuloma). The alternate terms run heavy for G06.1 as well. Here’s a full list, per ICD-10-CM:

• Abscess (embolic) of spinal cord [any part]
• Intraspinal epidural abscess or granuloma
• Intraspinal extradural abscess or granuloma
• Intraspinal subdural abscess or granuloma.