Pulmonology Coding Alert

Question: One of our asthma patients, who is self-administering Proventil, was planning a trip overseas. She came into the office to get a pulmonologists letter explaining her bronchodilator in case she has a problem with customs officials. She also wanted information on infectious disease prevention and possible drug interactions in other countries. How do we code for this?

Vermont Subscriber

Answer: Because the patient is concerned about managing her asthma with respect to infectious diseases and drug interactions, bill one of the evaluation and management codes for established patient visits (99212-99215) with the asthma diagnosis code (493.00-493.91). If the travel advice took up more than 50 percent of the encounter, you could determine the appropriate level of service depending on the time you spent counseling the patient. For documentation purposes, you should describe all of the services provided during the visit, indicate the total amount of time you spent during the encounter and the portion that was spent on counseling regarding the patients travel.