Outpatient Seizures Case Studies

Outpatient E/M Case Studies

Compare case studies of seizures patients at varying visit levels to better understand code selection for outpatient office encounters under the revised guidelines for 2021.


12-Year-Old Female with Seizures

Total Time* for Outpatient E/M in 2021

Refer to the following tables for correct code selection when billing based on time for outpatient E/M Services:

Total Time for Outpatient E/M
  CPT Code Time (In Minutes)
New Patient 99202
99203
99204
99205
15-29
30-44
45-59
60-74
Established Patient 99212
99213
99214
99215
10-19
20-29
30-39
40-54

*Total time includes non-face-to-face time on the date of service


Case 1: Level 3 ESTABLISHED (99213)

A 12-year-old female is brought by her mother for a follow-up of known complex partial seizure disorder on carbamazepine.

  • Pre-Visit: Reviewed prior clinic notes [2 MINS]
  • Visit: Performed medically appropriate history and exam. No recent reported seizures since carbamazepine was initiated. No signs of toxicity on exam. She and family are counseled about her diagnosis of epilepsy, seizure precautions. [20 MINS]
  • Post-Visit: Document encounter (3 MINS)

Problems Addressed Data Reviewed Patient Management Risk of Complications
One stable chronic illness Independent historian - history from mother Prescription drug management of carbamazepine
Low Limited Moderate

View MDM table for Seizures - 99213

Do I Code Based on Time or MDM?
Time MDM

Total time of visit (includes pre-visit and post-visit time on calendar day): 25 minutes

Established patient, level 3 = 20 to 29 minutes

CPT 99213

Problems addressed: Low

Data reviewed: Low

Risk of complications, M/M: Moderate

Level 3: Low

CPT 99213


case 2: level 4 established (99214)

Returns for a three-month follow-up visit and her mother denies witnessing any seizures and the patient denies side-effects.

  • Pre-Visit: Personally reviewed MR images which reported a cortical dysplasia in the left frontal lobe. Her EEG report was read as normal [5 MINS]
  • Visit: The significance of the cortical dysplasia was reviewed, as were images. No symptoms or signs of toxicity on exam. Oxcarbazepine was continued and appropriate surveillance labs were previously obtained and reviewed during the visit [25 MINS]
  • Post-Visit: Document encounter [3 MINS]

 

Problems Addressed Date Reviewed Patient Management Risk of Complications
One chronic illness with severe progression

Review PCP notes, labs, and neuropsych testing

Independent historian

Independent review of head CT

Prescription drug management
Moderate Extensive Moderate

View MDM table for Seizures - 99214

Do I Code Based on Time or MDM?
Time MDM

Total time of visit (includes pre-visit and post-visit time on calendar day): 33 minutes

Established patient, level 4 = 30 to 39 minutes

CPT 99214

Problems addressed: Moderate

Data reviewed: Extensive

Risk of complications, M/M: Moderate

Level 4: Moderate

CPT 99214


case 3: level 5 established (99215)

In the past six months, seizures became refractory to two medications, requiring multiple ED visits in the interim. She underwent a presurgical evaluation. You presented her at a multidisciplinary conference where surgery was recommended. 

  • Pre-Visit: You review the consensus recommendations, MR, PET, EEG, and neuropsychology report [7 MINS]
  • Visit: Discussion of surgical recommendations, treatment alternatives, and risk of sudden unexpected death in epilepsy patients with patient and parents. Referred patient to neurosurgery for formal consultation. You maintain oxcarbazepine, but increase clobazam [25 MINS]
  • Post-Visit: Place referral and send prescriptions, document encounter [4 MINS]

 

Problems Addressed Data Reviewed Patient Management Risk of Complications
One chronic illness with severe progression

Review PCP notes, labs, and neuropsych testing

Independent historian

Independent review of head CT

Prescription drug management

High Extensive High

View MDM table for Seizures - 99215

Do I Code Based on Time or MDM?
Time MDM

Total time of visit (includes pre-visit and post-visit time on calendar day): 36 minutes

Established patient, level 4 = 30 to 39 minutes

CPT 99214

Problems addressed: High

Data reviewed: Extensive

Risk of complications, M/M: High

Level 5: High

CPT 99215

Disclaimer:The billing and coding information provided by the American Academy of Neurology and its affiliates (collectively, “Academy”) are assessments of clinical information provided as an educational service. The information (1) is not clinical advice; (2) does not account for how private payers cover and reimburse procedures or services*; (3) is not continually updated and may not reflect the most current clinical information (new clinical information may emerge between the time information is developed and when it is published or read); and (4) is not a substitute for the independent professional judgment of the treating provider, who is responsible for correctly coding procedures and services.

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*The Academy recommends always checking private payer policies before rendering procedures or services