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tci E/M Coding Alert - 2022 Issue Q3

You Be the Coder: Figure Out Which Modifier is Best in This Arthrodesis Surgery Scenario

Question: Encounter notes indicate that the surgeon performed an office/outpatient evaluation and management (E/M) service for a new patient that lasted 57 minutes and involved high medical decision making (MDM). Then, they performed posterior spinal arthrodesis on four vertebral segments. How should I report this encounter? Arkansas Subscriber Answer: You should report 99205 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 60-74 minutes of total time is spent on the date of...

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