EM Coding Alert

Question: An established patient recently visited our pulmonology practice for a follow-up of their moderate persistent asthma. The pulmonologist performed spirometry with maximal voluntary ventilation before and after albuterol administration. Following review of the results, the pulmonologist considered the dose of the patient’s current albuterol medication and maintained it. How do we code this encounter?

Washington Subscriber

Answer: You’ll need two CPT^® codes and one ICD-10-CM code to report this encounter. Starting with the evaluation and management (E/M) code, you’ll assign 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter.). During the encounter, the physician ordered a spirometry test before and after a bronchodilator administration. The pulmonologist also reviewed the results of the testing and asked the patient to continue the current prescription. Since the patient was seen for their stable, chronic illness and continued the same prescription dosage, this information leads you to a low level of medical decision making (MDM).

Next, you’ll assign 94060 (Bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration) to report the spirometry testing before and after the albuterol administration.

Finally, you’ll assign J45.40 (Moderate persistent asthma, uncomplicated) to report the patient’s condition, which shows the medical necessity for the encounter.