Primary Care Coding Alert

Question: A patient suffered syncope and collapsed in the office, so our FP administered oxygen, providing one-on-one care until paramedics arrived. Should we use a critical care code for this, or a prolonged service code? How is the oxygen administration coded? Iowa Subscriber Answer: The coding options depend on the severity of the patient's condition and the amount of time the physician spends supervising and managing the patient. Your first thought is to go to the critical care codes (99291-99292). CPT says these codes require that a patient be critically ill, and that a critical illness "acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient's condition."

Although it is unknown in this scenario what has caused the syncope, there is no indication that the patient's current condition has reached the status stated above. Even though the syncope may be a precursor to a more severe condition, that condition has not yet presented itself. If the patient's condition does not warrant the use of critical care codes, other options must be considered.

First, a basic E/M service would absolutely be warranted. Based on the type of information available, with appropriate documentation to support the service, 99215 (Office or other outpatient visit for the evaluation and management of an established patient ...) would be a likely starting point. This code reflects the severity of the problem with the decision-making of high complexity, based on the fact that this was a new, unexpected problem that will require further evaluation and has high risk when considering the presenting problem and its treatment options.

The supporting documentation must demonstrate a complete history, including review of systems and past, family and social history, or a comprehensive examination of the patient. Otherwise, 99214 (Office or other outpatient visit for the evaluation and management of an established patient ...) would be appropriate. The next consideration is related to the amount of time spent with the patient. If the physician remained with the patient until paramedics arrived, you may be able to bill the prolonged service codes (99354-99355) as an added service.

Prolonged service codes are designed to compensate for additional time and services provided to patients beyond the basic E/M service that cannot be coded with some other more specific service. The rules state that the use of these codes is based on exceeding the basic time component of the base code by at least 30 minutes.

In this case, the basic time for 99215 is 40 minutes, so to bill the prolonged services codes the physician must provide at least 70 minutes of face-to-face supervision to the patient, and that time must be documented [...]