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:
| 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 |
| 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 |
| 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 |
| 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.
Using this information is voluntary. The Academy is providing the information on an “as is” basis and makes no warranty, expressed or implied, regarding the information. The Academy specifically disclaims any warranties of merchantability or fitness for a particular use or purpose. The Academy assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of this information or for any errors or omissions.
*The Academy recommends always checking private payer policies before rendering procedures or services