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Question: A 15-year-old patient reports to the neurosurgeon鈥檚 practice with complaints of confusion and seizures for the past day; for the three days before that, the patient suffered from vomiting and irritability. During the evaluation and management (E/M) portion of the service, the surgeon notes the patient had a recent viral infection and used aspirin to treat it. A computed tomography (CT) of the brain with contrast material confirms Reye鈥檚 syndrome. How should I report this encounter?

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Answer: On the claim, you should report the appropriate E/M code from the 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 15 minutes must be met or exceeded.) through 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 total time on the date of the encounter for code selection, 40 minutes must be met or exceeded.) code set with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure) appended to show that the E/M and CT were significant, separately identifiable services. Also, report 70460 (Computed tomography, head or brain; with contrast material(s)) for the CT scan.

Dx code conundrum: The ICD-10-CM code for Reye鈥檚 syndrome is G93.7 (Reye鈥檚 syndrome) 鈥� but it might not be the only code you鈥檒l need to complete the diagnosis picture for the patient. Though the exact cause of the syndrome is not known, there is a strong link between Reye鈥檚 syndrome and the use of aspirin (acetylsalicylic acid) in children and teenagers to treat viral infections. If the surgeon indicates that the aspirin use led to poisoning, you will report this first with a code from the T39.01- (Poisoning by, adverse effect of and underdosing of aspirin) set. So, you would report a T39.01- code first and G93.7 second in these situations.

If, however, the surgeon notes that the aspirin caused an adverse effect, you would choose a code from the T39.01-code set. So, you would report G93.7 to represent the Reye鈥檚 syndrome, then a T39.01- code to represent the adverse effect in these situations.

Chris Boucher, MS, CPC, Senior Development Editor, AAPC