tci General Surgery Coding Alert - 2021 Issue Q3

Reader Questions: Time is On Your Side

Question: I have a procedure note indicating that the provider performed an outpatient evaluation and management (E/M) service for an established patient. The physician documented a total encounter time of 46 minutes, and also documented performing moderate medical decision making (MDM). How should I code this? Georgia Subscriber Answer: 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...

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