Neurosurgery Coding Alert

Question: Encounter notes indicate that the surgeon performed an office evaluation and management (E/M) service for an established patient with a skull base fracture. The encounter involved high-level medical decision making (MDM) and lasted 54 minutes. How should I report this encounter?

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Answer: You’ll report 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.) for the E/M. As for the ICD-10 code, you’re going to need some more information in order to code correctly.

Step 1: Go back and check the notes, and then choose among these code sets:

• S02.10- (Unspecified fracture of base of skull)
• S02.11- (Fracture of occiput)
• S02.12- (Fracture of orbital roof)
• S02.19- (Other fracture of base of skull)

Step 2: In the above-listed code sets, find a code with a 6th character that matches your patient’s symptoms. For example, if the patient suffers from a right-sided type I occipital condyle fracture, you’d report S02.11A- (Type I occipital condyle fracture, right side).

Step 3: Choose the appropriate 7th character to finish off the code. Your 7th character options for skull fracture codes are:

• A = initial encounter for closed fracture
• B = initial encounter for open fracture
• D = subsequent encounter for fracture with routine healing
• G = subsequent encounter for fracture with delated healing
• K = subsequent encounter for fracture with nonunion
• S = sequelae.