ED Coding and Reimbursement Alert

Check out this anaphylaxis scenario and determine whether you can code it.

When patients with serious allergic reactions come to your emergency department, 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 eventually stabilizes. The physician documents the provision of greater than 30 minutes of critical care. 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 96372 (Therapeutic, prophylactic, 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 96372, you should also report J1094 (Injection, dexamethasone acetate, 1 mg) for the 1 mg of dexamethasone acetate that the physician injected and 18 units of J0171 (Injection, Adrenalin, epinephrine, 0.1 mg) for the epinephrine he administered.

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 for therapeutic purposes and/or for diagnostic purposes such as sputum induction with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device]) for the nebulized albuterol treatment.

Time Will Tell When It Comes to E/M Code

The patient’s symptoms were initially life-threatening, and greater 30 minutes of critical care are documented.

In this instance, you can choose to report 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])

Check Critical Care Code Criteria

Before you start reporting critical care codes, make sure you know the rules for procedure coding and diagnosis coding. 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.

Coding example: For instance, the patient may have difficulty breathing and go into shock. The physician must provide greater than 30 minutes of care to qualify for 99291.

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.

Important note: 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 intubates the patient, you should not include the time he spent performing the intubation in the time for critical care, since the intubation is reported separately.