Pediatric Coding Alert

Question: After a patient receives an allergy injection, she has an anaphylactic reaction to the injection. The pediatrician starts an IV to deliver fluids and 4 mg of dexamethasone. In addition, he administers 3 cc of epinephrine twice and 25 mg of Benadryl intramuscularly. The patient also requires oxygen. He spends another 30 minutes directly observing the patient. How should I code the treatments in the office and his time?

Florida Subscriber

Answer: You should report each service separately, starting with the original encounter the allergy injection. Code the injection with the appropriate injection code, such as 95120 (Professional services for allergen immunotherapy in prescribing physician's office or institution, including provision of allergenic extract; single injection).

Services such as nurse observation do not warrant billing a separate E/M. As CPT states, "Codes 95115-95199 include the professional services necessary for allergen immunotherapy." However, furnishing additional E/M services supports a nurse visit (99211). For instance, suppose a child has a local reaction to immunotherapy that requires additional history, dosage requirements and examination. Carefully document these services. Report 99211 appended with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).

A patient who has a severe reaction requires a physician's services. Therefore, you should report the appropriate established patient office visit code (99211-99215). The incident's seriousness and potential for morbidity probably involve a moderate to high level of medical decision-making and may justify billing 99214-99215. To indicate that the service constitutes a separate service, append modifier -25 to the office visit code.

If the pediatrician spends more than 30 minutes than the time CPT allows for the E/M code, you should report prolonged services. For instance, if your doctor indicates he performed a 99215 ( physicians typically spend 40 minutes) and remained with the patient for an additional 30 minutes, use +99354 (Prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service [e.g., prolonged care and treatment of an acute asthmatic patient in an outpatient setting]; first hour [list separately in addition to code for office or other outpatient evaluation and management service]). If he spends at least 75 minutes beyond the time allotted for the E/M code, assign +99355 ( each additional 30 minutes [list separately in addition to code for prolonged physician service) for each additional 30 minutes.

Although you did not indicate how much initial time your doctor spent with the patient, to bill +99354 your doctor must have documented 70 minutes of total face-to-face time.

Note: Many physicians overlook charging prolonged services, which reimburse in excess of $100. However, thorough documentation is required to capture this opportunity.

For the IV infusion, assign 90780 (IV infusion for therapy/diagnosis, administered by physician or under direct supervision of physician; up to one hour) for the administration of the dexamethasone and fluids. If the IV infusion continued longer than one hour, you should also report add-on code +90781 (... each additional hour, up to eight [8] hours [list separately in addition to code for primary procedure]).

Although the E/M service usually includes the administration of epinephrine and Benadryl injections, code the medications with the appropriate supply code. For each injection of epinephrine, bill J0170 (Injection, adrenaline, epinephrine, up to 1 ml ampule). Code the Benadryl J1200 (Injection, diphenhydramine HCl, up to 50 mg). For each mg of dexamethasone delivered, assign J1095 (Injection, dexamethasone acetate, per 8 mg) or J1100 (Injection, dexamethasone sodium phosphate, 1 mg). Possible codes for the IV fluids include J7042 (5% dextrose/normal saline [500 ml = 1 unit]) and J7120 (Ringer's lactate infusion, up to 1,000 cc).

No CPT code exists for the oxygen administration, which is also included in the E/M. You may use critical care codes (99291-99292) if the patient has a severe anaphylactic reaction. However, a patient of this severity would probably warrant admission.

Clinical information for You Be the Coder and Reader Questions provided by Nancy Bischof, MD, private practice, Lexington, Ky.; and Richard H. Tuck, MD, FAAP, medical director of quality care partners, PrimeCare Pediatrics, Zainesville, Ohio.