E/M CODING FOR MULTIPLE MINOR INJURIES
When selecting the number and complexity of problems addressed at an office visit, which level is appropriate for evaluating and treating minor injuries to multiple sites (e.g., multiple lacerations of the foot not requiring surgery)?
Evaluation and management (E/M) of multiple acute uncomplicated injuries equates to a low number and complexity of problems addressed. According to the American Medical Association's medical decision making chart,1any injury moves the problems portion of the visit from a straightforward/minimal level to a low level. But to reach a moderate level requires treating at least one acute complicated injury (i.e., an injury that is extensive, requires evaluation of body systems not directly part of the injured organ, or has multiple treatment options or treatment options associated with risk of morbidity). To reach a high level, the injury or injuries must threaten the patient's life or bodily functions.
Reference(s)
- 1.Table 2 — CPT E/M office revisions level of medical decision making (MDM). American Medical Association. Accessed Jan. 30, 2024. https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf
TOBACCO DEPENDENCE AS CHRONIC CONDITION
For E/M code selection, does dependence on tobacco or nicotine count as a chronic condition when I develop or monitor a plan to help my patient quit?
Yes, the Centers for Disease Control and Prevention designates tobacco dependence as a chronic and relapsing condition. But you should only count this toward E/M code selection if you evaluate the patient's current tobacco/nicotine use and its effect on other conditions, and address the problem at that visit.
BIRTH DEFECT DISCOVERED IN ADOLESCENCE
What is the appropriate diagnosis code for a patient who has had a heart defect since birth that wasn't discovered until adolescence?
ICD-10 guidelines instruct you to assign a code for the specific congenital heart defect (Q20-Q24) for as long as the defect is present. If the defect has been repaired, report Z87.74, “Personal history of (corrected) congenital malformations of heart and circulatory system.” You may report code Z09 (follow-up care) primary to Z87.74 when you provide a follow-up service for the congenital condition.
E/M SERVICE FOR PATIENT WITH IMPENDING RESPIRATORY FAILURE
How do I report an E/M service when an established patient presents with impending respiratory failure and requires 45 minutes of critical care prior to transport via ambulance to an emergency department?
Report code 99291, because you spent at least 30 minutes providing critical care (defined as the direct delivery by a physician or other qualified health care professional of medical care for a critical illness or injury that acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient's condition). If you had provided less than 30 minutes of critical care, consider code 99215 (or 99205 for new patients) based on the high-complexity problem and risk associated with emergency transportation and possible hospitalization.
ORDER AND INDEPENDENT INTERPRETATION OF X-RAY
I ordered an x-ray during a patient's office visit and later that day reviewed the image and documented my interpretation (pending the radiologist's interpretation and report). Can I count both the order and the independent interpretation of the x-ray toward the data reviewed and analyzed at this visit?
Yes. Nothing prohibits a physician from taking credit for both ordering and independently interpreting a test for which another physician will bill for the interpretation. However, you may only count both the order and the independent interpretation for tests that have a professional and technical component (e.g., x-ray), and you may not count either toward your medical decision making if your practice is billing separately for the test. Note that if you were only reviewing test results (e.g., the results of a complete blood count, which would not require interpretation), you could only count the order or review.
