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Question: An established patient presents with a three-day history of increasing redness, warmth, swelling, and tenderness of the left lower leg. The patient reports the symptoms began after scratching an area of dry skin near the ankle and have gradually worsened. The physician documents mild localized edema and an erythematous area extending from the ankle toward the mid-calf, without abscess or purulent drainage. The patient is afebrile in the office, and the physician diagnoses cellulitis of the left lower limb and prescribes oral antibiotics. Should I code cellulitis and then include signs and symptoms?

Virginia Subscriber

Answer: Once the provider has documented a definitive diagnosis, you don’t need to report signs and symptoms as well. In your ICD-10-CM code book, you can find the best code for this situation by looking to L03.116 (Cellulitis of left lower limb.)

To code the encounter, check the documentation again to determine the medical decision making (MDM) level before you select the appropriate evaluation and management (E/M) code. You know you’ll be using an established patient office/outpatient code from the 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient …) range. From there, you need to figure out which level is appropriate.

In this scenario, the diagnosis of cellulitis represents an acute, uncomplicated illness, but the key driver is risk. As the documentation includes a new prescription for oral antibiotics, the encounter meets the definition of moderate risk according to the 2021-2026 E/M guidelines.

If the documentation doesn’t clearly support moderate MDM beyond the prescription, then 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 moderate level of medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded) is your best bet. 

If the documentation supports the encounter including at least one other element (problem, data, or risk) at the moderate level, then coding to a higher level with 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.) may be appropriate.

Don’t forget to review the patient’s record for any additional data reviewed, comorbidities, or management considerations that would further support moderate complexity before assigning the higher-level code.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Production Editor, AAPC