Gastroenterology Coding Alert

Question: A 50 year old male has persistent vomiting and gastroenteritis. On assessment, the patient demonstrates the signs of dehydration, such as dry lips, dry axilla and loss of skin turgor.

After basic E/M, the provider decides to start intake of oral rehydration solution. The provider monitors the patient’s status for two hours thereafter, till he decides the patient’s condition to be stable. How do we report this case scenario?

Texas Subscriber

Answer: In this case scenario, you may begin with reporting a primary E/M service code 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity).

This case signifies prolonged service by the physician for 120 minutes. Therefore you may report prolonged service codes 99415 (Prolonged clinical staff service [the service beyond the typical service time] during an evaluation and management service in the office or outpatient setting, direct patient contact with physician supervision; first hour [List separately in addition to code for outpatient Evaluation and Management service]), for the first 45-74 minutes.

Thereafter, for each additional up to 30 minutes, you may report a single unit of 99416 (Prolonged clinical staff service [the service beyond the typical service time] during an evaluation and management service in the office or outpatient setting, direct patient contact with physician supervision; each additional 30 minutes [List separately in addition to code for prolonged service]).

In this case, you may report 99415, along with 2 units of 99416.