Neurosurgery Coding Alert

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

Wisconsin Subscriber

Answer: CPT limits use of emergency department service codes (99281-99285, Emergency department visit for the evaluation and management of a patient ...) to organized, specifically defined "hospital-based facilit[ies] for the provision of unscheduled episodic services to patients who present for immediate medical attention." In addition, the facility must be available 24 hours a 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 code (for example, 9921x, Office or other outpatient visit for the evaluation and management of an established patient) would be appropriate.

To report 99291, there must be "a high probability of imminent or life-threatening deterioration in the patient's condition," according to CPT. And, the physician must spend at least 30 minutes providing critical care while in proximal contact with the patient. "Time that can be reported as critical care is the time spent engaged in work directly related to the individual patient's care whether the time was spent at the immediate bedside or elsewhere on the floor or unit," CPT says. You must carefully document all critical care time, and you cannot include the time spent providing other, separately reportable procedures (such as cardiopulmonary resuscitation).

If the physician completed the E/M service before the anaphylactic episode, you may report both the E/M service and critical care, although you will have to 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 former code.

In most cases, the patient will stabilize or the ambulance will arrive before the physician reaches the time threshold for critical care. In these cases, CPT advises physicians to report the appropriate E/M code. Assuming the patient you describe was established to your practice, a high-level service such as 99214 or 99215 would be appropriate with documentation explaining the nature of the services provided.

You may also bill other separately reportable services. For example, if the surgeon 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 that the payer recognizes the E/M or critical care as well as these services, append modifier -25 to the E/M code.

Finally, report 99058 (Office services provided on an emergency basis). According to CPT Assistant, Winter 1994, "If a patient presents at the physician's office and requires unscheduled emergency care, code 99058 is reported in addition to the other services provided. This is reported for those office patients whose condition, in the clinical judgment of the physician, warrants the physician's interrupting his or her care of another patient to deal with the 'emergency.' This code is not reported when the doctor's practice is to have urgent care slots available in the schedule and patients are 'fit in' to the schedule." But you will likely receive no additional reimbursement for 99058.