IV infusion, planned?!

jaldrich

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I'm having trouble coding this visit. It looks like a planned IV placement for testing. Patient was in 2 days prior and this visit was a follow up to that visit. How would you code this? Iv infusion only? or would you give an E/M AND Infusion? Also, I didn't see a code for the med that was infused. Should I use J3490?
Thanks in advance




PROBLEM: Diplopia.

S: Patient returns today for further testing. He has had sudden onset of diplopia and the differential of this has been the possibility of Myasthenia Gravis. He has typically been noting his diplopia to worsen in the afternoons and therefore was asked to return to the office this afternoon at a time when he is most likely to be symptomatic. He is here today to receive Tensilon (edrophonium) injection.

O: GENERAL: He is alert and appropriate. He does not appear to be in any particular distress at this time.

VITAL SIGNS: Stable.

An IV was implemented. Normal saline was used as a continuous infusion. He was given a test dose of 0.2 mL of Enlon intravenously over approximately 30 seconds. No significant symptoms were noted. He was then given an additional 0.8 mL which then totalled 10 mg. Although the directions had suggested a response within 30 to 60 seconds, he did not get a response from approximately two minutes. At that time, he became diaphoretic and his diplopia nearly totally resolved. It was a dramatic improvement. Approximately 8 to 10 minutes later diplopia returned.



A: Positive Tensilon test. This is certainly very supportive of Myasthenia Gravis.



P: He is sent for antibody determinations. This will include acetylcholine receptor antibodies which are generally positive in about 70 percent of Myasthenia. After those levels have been obtained, we will then discuss potential therapy. I did contact Dr. X today to advise him of the positive findings.
 

Erica1217

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I would bill this an IV Push only. The E&M service was not above & beyond what is required to accomplish the procedure. There is a little history, but it sounds like the provider is just summarizing from the visit 2 days prior and he specifically says the patient is here for testing.

The documentation shows the IV infusion only lasted a couple of minutes and CPT says infusions less than 15 minutes are coded as a push, 90774.

Yes, you'll have to use J3490.. there still isn't a code for this.

:) Erica
 
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