Pediatric Coding Alert

Try to use CPT®, ICD-9 and ICD-10 codes for this visit.

Now that the calendar has turned to 2015, we’re in the same year that ICD-10 will be taking effect, so it’s time to once again test yourself using a documentation example to determine which codes you would report, then read on for the answers.

Example: You see an established four-year-old male patient who has a history of asthma. During the expanded, problem-focused history, the physician finds an intermittent night time cough, with occasional episodes of wheezing, relieved using an albuterol MDI. No restrictions of activity were noted. No one else in the family is sick, and the parents both smoke.

The patient’s vitals were within normal limits, pulse oximetry was documented at 98 percent and no respiratory distress was observed. The detailed exam indicates that the pediatrician heard rare expiratory wheezes. He makes a diagnosis of asthma using current asthma diagnosis guidelines.

You discuss the diagnosis in detail with the patient’s mother, including management of asthma using rescue (albuterol) and controller (inhaled steroid) MDIs. The use of MDIs with a spacer is discussed, demonstrated, and documented. A follow-up visit is scheduled in two weeks.

How would you code this case?

CPT® Codes: You should report 99214 (Office or other outpatient visit for the evaluation and management of an established patient…) for the E/M service. Next you’ll bill the pulse oximetry with 94760 (Noninvasive ear or pulse oximetry for oxygen saturation; single determination) and the MDI education with 94664-59 (Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device; Distinct procedural service). Although not required, a 25 modifier might be necessary on the E/M code to separate it from the other services.

ICD-9 Code: Until Oct. 1, 2015, you’ll report 493.00 (Extrinsic asthma unspecified).

ICD-10: After Oct. 1, you will report the ICD-10 codes J45.21 (Mild intermittent asthma with [acute] exacerbation) and Z77.22 (Contact with and [suspected] exposure to environmental tobacco smoke [acute] [chronic]) to represent the fact that the patient’s parents smoke.