Primary Care Coding Alert

Question: A 52-year-old female patient (non-Medicare) suffering from hypertension is taking a new medication to control her condition and is experiencing dizziness, nausea, and fatigue. She e-mails her FP about her symptoms, along with a list

of her blood pressure readings since changing the medication 10 days ago. She inquires if she should come in for an office visit or if the physician should change her medication. The FP reviews the patient's symptoms along with her chart history

and pressure readings and suggests the patient is suffering from rare side effects to the medication. She replies to the patient's e-mail and directs her to online information on the drug. The physician also tells the patient that she is faxing in a

new prescription that will not cause these side effects. How should I code this service?

Ohio Subscriber

Answer: This may count as a virtual visit, which you would code as 99444 (Online evaluation and management service provided by a physician to an established patient, guardian, or health care provider not originating from a related E/M service

provided within the previous 7 days, using the Internet or similar electronic communications network). For the diagnoses, list the appropriate hyper-tension diagnosis code, such as 401.x (Essential hyper-tension), along with 995.2x (Other and

unspecified ad-verse effect of drug, medicinal, and biological substance).

When using 99444, the physician must reply to the patient's online inquiry in a timely manner. Your practice must also permanently store either an electronic or hard copy of the encounter. Also, you can report this code only once during a seven-

day period for any and all replies related to the patient's question.