Internal Medicine Coding Alert

Question: Which code should we report when the doctor spends 15-20 minutes observing the patient after administering an allergy injection? Can we bill 99213?


Connecticut Subscriber

Answer: When a patient receives an allergy injection, physicians typically have the patient wait in the office to detect any adverse reactions to the injection.

You should not bill for the time the physician spends monitoring the patient separately from the injection. If the physician provides a service separately identifiable from the injection (such as an asthma evaluation), you should then consider reporting an E/M code (99212-99215) that reflects the appropriate service and the documentation included in the medical records.

Example: An established 32-year-old female patient comes to your practice for an allergy injection. After he administers one injection, the physician advises the patient to sit in the waiting room for 20 minutes so he can make sure she does not have an adverse reaction to the injection.

After 20 minutes, the patient reports shortness of breath (786.05). The physician decides to evaluate the patient to determine whether this is an adverse reaction to the injection or a simple asthma flare. In this instance, you should report 95115 (Professional services for allergen immunotherapy not including provision of allergenic extracts; single injection).
 
Because the physician also administered a baseline spirometry to check for decreased lung function, you should report 94010 (Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation) and 99214 (Office or other outpatient visit for the evaluation and management of an established patient ...) for the E/M services the physician performed as a result of the patient's condition if the documentation supports it.

Answers for You Be the Coder and Reader Questions were reviewed by Kathy Pride, CPC, CCS-P, a coding consultant for QuadraMed in Port St. Lucie, Fla.; and Bruce Rappoport, MD, CPC, a board-certified internist who works with physicians on compliance, documentation, coding and quality issues for Rachlin, Cohen & Holtz LLP, a Fort Lauderdale, Fla.-based accounting firm with healthcare expertise.