EM Coding Alert

Question: The physician saw a 24-year-old new female patient for complaints of high fever, vomiting, pain and burning sensation during urination, and radiating pain along the flank and back. The physician evaluated the patient and arrived at a diagnosis of acute pyelonephritis. He decided to administer cefazolin sodium to help bring the infection under control. What codes should we report?

Colorado Subscriber

Answer: In this case, the physician administers an injection to alleviate the problem that the patient is facing. So, the reason for your physician administering the injection is directly related to the reason for the office visit.

"To bill an E/M service with a minor office procedure (such as an injection), you must have documentation supporting the need for an additional assessment beyond that for the injection," says Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania.

You will report the following codes for the encounter:

• Appropriate code from 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient ...) depending on history, exam, and medical decision making with modifier 25 appended
• 96372 for the administration of the cefazolin sodium
• J0690 (Injection, cefazolin sodium, 500 mg) for the medication that was administered
• N10 (Acute pyelonephritis) for the diagnosis.

Caution: In such a scenario, you'll lose out on deserved pay if you're not capturing the administration of the injection by reporting 96372 in addition to the E/M code you report. You will have to report the 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 or other service) with the E/M code to allow reporting of both the codes together for the samevisit. Per CPT^®, the E/M service may be prompted by the symptom or condition for which the procedure and/or other service was provided when using modifier 25.