Neurology & Pain Management Coding Alert

Question: Encounter notes indicate that a patient reported to the office for evaluation and management (E/M) of a blepharospasm. The visit lasted 22 minutes and involved straightforward medical decision making (MDM). What ICD-10 and CPT^® codes should I report for this service?

Kentucky Subscriber

Answer: You’ll have two choices for the blepharospasm. If it was not drug-induced, you’ll opt for G24.5 (Blepharospasm). If the ailment was drug-induced, then you’ll report G24.01 (Drug induced subacute dyskinesia).

G24.01 is a catch-all code for drug-induced dystonias; you should use it to report:

• Drug-induced blepharospasm,
• Drug-induced orofacial dyskinesia,
• Neuroleptic-induced tardive dyskinesia, and
• Tardive dyskinesia.

If any of the above conditions is not drug-induced, opt for the standard ICD-10 codes for each respective condition.

Px status issue: As for the E/M service, you’ll need to know whether the patient was new or established before reporting the code. For a new patient, report 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/ or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter.) For an established patient, 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 time for code selection, 20-29 minutes of total time is spent on the date of the encounter.)