Primary Care Coding Alert

You could be losing out when your family practitioner (FP) treats bee-venom-triggered anaphylaxis in the office, but coding experts say you'll boost reimbursement if you zero in on the time and complexity of the anaphylactic-shock services the FP provides. 1. Use 99291-99292 for Life-Saving Measures  Although some coders think that 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and +99292 (... each additional 30 minutes [list separately in addition to code for primary service]) are for hospital use only, you may use these high-paying codes in the office if you follow CPT's guidelines for reporting critical care services, says Diane M. Minard, CPC, a coding specialist for Dartmouth Hitchcock Medical Center in Lebanon, N.H. The Medicare Physician Fee Schedule, which many private payers use as a guide, pays a geographically unadjusted nonfacility rate of $210.07 for 99291 and $107.79 for 99292.
 
Indeed, in some instances of anaphylaxis due to bee or wasp venom, the patient's condition may require critical care services.
 
For instance, a patient who has an anaphylactic reaction to a bee sting may experience respiratory distress, vascular collapse, shock, urticaria (hives), angioedema and pruritus. If the episode meets the criteria for billing critical care services, using a higher-level office visit code, such as 99214 (Office or other outpatient visit for the E/M of an established patient ... physicians typically spend 25 minutes face-to-face with the patient and/or family) instead of 99291-99292, will cost your practice $130.24.
 
But before you start reporting critical care codes, make sure you know the rules. CPT defines a critical illness or injury as one that impairs one or more vital organ systems, creating a high probability of imminent or life-threatening deterioration in the patient's condition.
 
Therefore, if the severe systemic reaction to the insect sting becomes life-threatening and affects one or more of the patient's vital organ systems, and the physician provides direct medical care, critical care services may apply, Minard says. For instance, the patient may have difficulty breathing and go into shock. The physician must continue the life-sustaining services for 30 minutes, however, to qualify for 99291.
 
Although the physician does not usually provide these services in the office for an extended time, he or she may perform them until the patient can be transported to a hospital or critical care unit. 2. Fall Back on E/M Codes Even so, in many instances of anaphylaxis, the patient may respond to treatment before qualifying for the 30 minutes necessary to bill 99291.
 
The question to ask is, did the physician spend 30 minutes providing critical care to the patient? In most cases, epinephrine will resolve the condition before that, says Susan Callaway, CPC, CCS-P, an independent coding [...]