Pediatric Coding Alert

Answer: Assuming that when a patient comes into the office in distress due to an allergic reaction, he or she is examined and treated but must remain in the office setting to be observed as to the effectiveness of the treatment, then CPT code 99214 is probably appropriate for the level of care. But remember that this code may not be sufficient for the complexity of medical decision or the time spent with the patient or family. Code 99214 is typically 25 minutes face to face, and CPT 99215 is 40 minutes.

Remember that face-to-face time is that which is associated with the services described for an E/M code for the total work done before, during, and after the visit. If 40 minutes were spent, the provider probably devoted most of that time to giving care and talking with the patient or family. Therefore, a 99215 would be justified. It is extremely important to have proper documentation for all of the care provided during the course of the office stay. Additionally, the use of code 99354 may be charged in addition to the E/M code as long as the total duration of the prolonged service is greater than 30 minutes.

However, if the observation is just a matter of the patient sitting in the waiting room, during which time the nurse looks in on the child occasionally, or maybe only at the end of the allotted time, you cannot bill. The physician must be involved in face-to-face time during the observation for it to be billable.