Neurosurgery Coding Alert

Question: Notes indicate that the provider performed an office evaluation and management (E/M) service for a patient with a diagnosis of multiple sclerosis (MS) of the brain stem. The encounter lasted 47 minutes and included moderate medical decision making (MDM). What codes should I select for this encounter?

Georgia Subscriber

Answer: Your code choice will depend on whether the patient is new or established; and given the new rules that allow you to code based solely on encounter time or MDM, there’s a difference in how you’ll choose the codes.

New Px: If the patient is new, you should report 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is spent on the date of the encounter.), as this visit hits the marks for time (47 minutes) and MDM (moderate).

Established Px: If the patient is established, you should 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.). Even though the MDM is still moderate for the encounter, you’ll choose 99215 because it fits the time parameters in the descriptor — making time the component you should use when deciding on an E/M code.

ICD-10 code: Whether you report 99204 or 99215 for this patient, append G35 (Multiple sclerosis) to represent the patient’s MS. Though MS of the brain stem doesn’t have its own code in ICD-10, it is considered synonymous with MS.

Other conditions that are synonymous with MS, and thus coded with G35, include:

• Disseminated MS
• Generalized MS
• MS NOS
• MS of cord.