Revenue Cycle Insider

Question: An established patient with atrial fibrillation returns urgently to the cardiology office three days after starting amiodarone, as prescribed by the cardiologist. The patient reports dizziness, near syncope, palpitations, and profound fatigue. In the office, blood pressure is 78/52 and heart rate is 42. The cardiologist documents symptomatic drug-induced hypotension and bradycardia due to amiodarone. The physician performs a medically appropriate history and examination, reviews the recent medication change and prior electrocardiogram (ECG), independently interprets a 12-lead ECG obtained in the office showing marked sinus bradycardia, discontinues amiodarone immediately, contacts the emergency department (ED) to arrange direct transfer for urgent evaluation and possible admission, and documents 42 minutes of total physician time on the date of the encounter. How should we code this?

Alabama Subscriber

Answer: Report evaluation and management (E/M) code 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.) for the encounter.

Current office/outpatient E/M rules allow code selection based on either medical decision making (MDM) or total time, and this scenario involves enough MDM, as well as enough time,  to support 99215 rather than 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.).

For the diagnoses, look to ICD-10-CM Official Guidelines for Chapter 19: Injury, Poisoning and Certain Other Consequences of External Causes. The guideline states: “When coding an adverse effect of a drug that has been correctly prescribed and properly administered, code the nature of the adverse effect first, followed by the appropriate code for the adverse effect of the drug (T36-T50 with 5^th or 6^th character 5).”

Do not report a poisoning code unless the documentation shows an overdose, wrong substance, or incorrect administration. When the medication was prescribed correctly and taken as directed, and the patient experienced a reaction, code the encounter as an adverse effect.

Accordingly, you should report the manifestation diagnosis first: I95.2 (Hypotension due to drugs). Then report the adverse effect code for the drug responsible for the reaction. The cardiologist documented amiodarone as the cause, so you can assign T46.2X5A (Adverse effect of other antidysrhythmic drugs, initial encounter).

Rachel Dorrell, MA, MS, CPC-A, CPPM, Production Editor, AAPC