Neurosurgery Coding Alert

Question: Our surgeon performed a level-four E/M service on a new patient last week. The visit lasted an hour, yet CPT estimates the physician would spend only 45 minutes face-to-face with the patient for a level-four new patient E/M service. Can I append modifier 21 to the E/M code to account for the extra time?


Mississippi Subscriber


Answer: You cannot append modifier 21 (Prolonged evaluation and management services) to a level-four E/M service. You can only append modifier 21 to the top-level service in any code category (such as new patient office visit). That means you can only use it with level-five (99205) services

You should report only 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a comprehensive history, a comprehensive examination, medical decision-making of moderate complexity) for the E/M service.

But if the surgeon had spent 75 minutes with the patient, or performed only a level-three service (99203, which has an estimated time of 30 minutes), he would have been able to bill +99354 (Prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service [e.g., prolonged care and treatment of an acute asthmatic patient in an outpatient setting]; first hour [list separately in addition to code for office or other outpatient evaluation and management service]).