Pediatric Coding Alert

If you give allergy shots, you have to be prepared for an anaphylactic reaction. And as June Beetler, DO, of the Johnston Pediatric Clinic in Johnston, IA discovered, it helps to be prepared for coding the claim as well. We give a weekly allergy shot to an 11-year-old girl, Beetler writes. Last week she had an anaphylactic reaction requiring subcutaneous epinephrine x 2, IV fluids, IV Benadryl, and continuous monitoring by the physician for about 50 minutes. How should we have coded this?

Use Prolonged Services Codes

You could use the prolonged services codes (99354-99355), responds Evelyn Lamberty, office manager for Virginia Allergy and Pediatrics, a four-pediatrician, one-allergist practice in Fairfax, VA. These codes are to be used when the physician provides services involving direct (face-to-face) patient contact that is beyond the usual service, CPT states.

The code that should be used in Beetlers scenario is CPT 99354 , says Lamberty. This code must be added on to the office-visit code, which would probably be 99213, although, depending on the severity of the reaction, you might be able to use 99214 instead for the office visit, she says.

99354 starts at 30 minutes, and covers additional time spent through 75 minutes. This is an important point: the first 30 minutes of the office visit do not count toward prolonged services. Prolonged service of less than 30 minutes total duration on a given date is not separately reported because the work involved is included in the total work of the evaluation and management codes, CPT states.

Aside from the extra time spent with the patient, another problem is getting reimbursed for the medications, the office manager adds. CPT states that these are separately reportable in the prolonged services codes section: Appropriate codes should be selected for supplies provided or procedures performed in the care of the patient during this period. However, reimbursement is another matter. Lamberty has found that payers commonly dont reimburse the CPT codes for administration of Benadryl or epinephrine injections (90782, therapeutic or diagnostic injection [specify material injected]; subcutaneous or intramuscular; or 90783, intra-arterial, 90784, intravenous). Sometimes I have to use HCPCS [supply] codes, she says.

Note: The HCPCS codes for these medications are J1200 for Benadryl, and J0170 (injection, adrenalin, epinephrine, up to 1 ml ampule) for epinephrine.

Use the -25 Modifier

If there were not an allergic reaction, you would normally code only 95115 for the allergy shot if you are not providing the extract, and 95120 if you are providing the extract. But, CPT states that office visit codes may be used in addition to allergen immunotherapy if other identifiable services are provided at that time. This raises the question of whether you need to use a -25 modifier on a separate office/outpatient E/M code to indicate that treating the anaphylactic reaction was a separate service from administering the allergy shot.

I would use the modifier -25 because taking care of the reaction is something separate from giving the injection, says Lamberty. The patient came in for an allergy shot. She had a reaction. Usually the insurance company wont pay for the visit and the allergy shot unless you use the modifier -25.

Would the insurance company view the reaction as related to the shot, and deny the E/M code based on that relationship? Lamberty says no, the insurance company will not deny the claim based on that relationship. For the practice, the shot and the reaction are related, but for the insurance company, they arent, she says.

Also, you do not have to have separate diagnoses for each procedure to use the modifier -25. The EM service may be prompted by the symptom or condition for which the procedure and/or service was provided, CPT 1999 states. As such, different diagnoses are not required for reporting of the E/M services on the same date.