Pulmonology Coding Alert

Test your knowledge against the following scenario and see if you make the anaphylaxis A+ grade

When patients with serious allergic reactions come to your practice, you should know when you're justified in reporting E/M and/or critical care codes.

Take a look at the following complex scenario to help stay on top of your game when your physician provides anaphylactic-shock services. Write down your code choices before looking to the correct coding solution below.

The Scenario: Patient Has Severe Reactions

A 25-year-old female patient comes in after a yellow-jacket sting. The sting site shows signs of swelling and redness.

During the examination, the patient begins to wheeze. Her blood pressure drops. She shows signs of abdominal cramping and altered consciousness. The physician intramuscularly administers 1 mg of dexamethasone acetate and 0.18 ml of epinephrine.

After about five minutes, the patient's signs begin to subside, and the physician gives a shot of 25 mg of diphenhydramine hydrochloride and administers a nebulized albuterol treatment.

The patient's condition is stable within 15 minutes. The physician and a nurse monitor the patient off and on during the next three hours.

The Solution: Watch Drug Administration, E/M Services

In the above instance, you should report G0351 (Therapeutic or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular) x 3 for the intramuscular dexamethasone acetate injection, the epinephrine injection, and the diphenhydramine hydrochloride injection.

In addition to G0351, you should also report J1094 (Injection, dexamethasone acetate, 1 mg) for the 1 mg of dexamethasone acetate that the physician injected and J0170 (Injection, adrenaline, epinephrine, up to 1-ml ampule) for the epinephrine he administered, says Alan L. Plummer, MD, professor of medicine, Division of Pulmonary, Allergy and Critical Care at Emory University School of Medicine in Atlanta.

Next: Report J1200 (Injection, diphenhydramine HCl, up to 50 mg) for the 25 mg of diphenhydramine hydrochloride and 94640 (Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes [e.g., with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device]) for the nebulized albuterol treatment, Plummer says.

Time Will Tell When It Comes to 99214 or 99291

Although the patient's symptoms were initially life-threatening, she shows signs of organ stability prior to reaching the 30 minutes of instability necessary to bill critical care services.

In this instance, you can choose to report a high-level E/M code, such as 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a detailed history; a detailed examination; medical decision-making of moderate complexity ...) or 99215 (... a comprehensive history; a comprehensive examination; medical decision-making of high complexity ...), in addition to the other procedure and drug codes, Plummer says.

Alternative: You can also take your pick of a critical care code (such as 99291, Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes or +99292, ... each additional 30 minutes [list separately in addition to code for primary service]) if the patient was unstable for 30 minutes or longer, Plummer says, as long as you follow CPT's guidelines for reporting critical care services. 

Bonus: You should also append modifier -25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to the appropriate E/M or critical care code, if the payer requires it, to show that the physician completed an office visit as a significant, separately identifiable service from the procedures, Plummer says.

Check Critical Care Codes Criteria

Before you start reporting critical care codes, make sure you know the rules for procedure coding and diagnosis coding, says Beverly Ramsey, CMA, CPC, CHCC, CHBC, at Doctors Management in Asheville, N.C.

CPT defines a critical illness or injury as one that impairs one or more vital organ systems, creating a high probability of imminent or life-threatening deterioration in the patient's condition.
 
Therefore, if the severe systemic reaction to the insect sting becomes life-threatening and affects one or more of the patient's vital organ systems (e.g., respiratory distress), and the physician provides direct medical care, you should report critical care services, Ramsey says. 

Coding example: For instance, the patient may have difficulty breathing and go into shock. The physician must continue the life-sustaining services for 30 minutes, however, to qualify for 99291, Ramsey says.

Although the physician does not usually provide these services in the office for an extended time, he may perform them until the patient can be transported to a hospital or critical care unit, Ramsey says.

Red flag: If your physician provides critical care services that do not total 30 minutes, CPT advises you to report appropriate-level E/M codes instead (such as one of the established patient office visit codes from the 99212-99215 range). 

Important note: The physician's time is the only  time that you should consider when reporting your critical care services. You should not take into account the time that office staff contributes to the critical care time reported. 

And you should not count any time associated with a separately billable procedure performed by the physician during the critical care service in the critical care code you choose. 

For example, if the physician administers inhalation treatment to a patient, you should not include the time he spent administering the inhalation treatment in the time for critical care, since you will report the inhalation treatment separately.