Neurology & Pain Management Coding Alert

Question: Recently, an allergy patient presenting for evaluation of carpal tunnel experienced anaphylactic shock while in the office (unrelated to the procedures the neurologist was performing). The neurologist provided care until an ambulance arrived. May we use the emergency department codes to report this service?

Colorado Subscriber

Answer: Emergency department service codes 99281-99285 (Emergency department visit for the evaluation and management of a patient ...) are limited to use in organized, specifically defined "hospital-based facilit[ies] for the provision of unscheduled episodic services to patients who present for immediate medical attention," according to CPT. In addition, the facility must be available 24 hours per day. Therefore, 99281-99285 are inappropriate for "emergency" care provided in the physician office.
 
Depending on the severity of the shock and the time the physician spent providing care, either 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) or an office visit/consultation code (for example, 9921x, Office or other outpatient visit for the evaluation and management of an established patient), is appropriate. To report 99291, there must be "a high probability of imminent or life-threatening deterioration in the patient's condition," according to CPT. In addition, the physician must spend at least 30 minutes providing critical care while in direct contact with the patient. Time spent away from the patient does not count toward critical care unless the patient is unable to communicate and the physician must consult with others to gain a medical history and review the patient's condition. All critical care time must be well documented and cannot include time spent providing other, separately reportable procedures (such as CPR, for example).
 
In most cases, the patient will stabilize or the ambulance will arrive before the time threshold for critical care is met. In these cases, CPT advises physicians to report the appropriate E/M code. Assuming that the patient you describe was established to your practice, a high-level outpatient service such as 99214 or 99215 would be appropriate with documentation explaining the nature of the services provided.
 
Other, separately reportable services should also be billed. For example, if the neurologist provides CPR to an unconscious patient, you may report 92950 (Cardiopulmonary resuscitation) in addition to the appropriate E/M or critical care code. To ensure the carrier recognizes the evaluation and management/critical care service in addition to these services, append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code.