Primary Care Coding Alert

Question: The FP meets a 46-year-old established female patient at the local hospital at 2 p.m. Wednesday; she has suffered syncope secondary to severe dehydration due to her influenza. The physician documents a comprehensive history, comprehensive exam, and medical decision making of moderate complexity. The physician and staff work to rehydrate the patient and provide her with anti-nausea medicine; she responds positively to both treatments. Blood work reveals she is adequately hydrated and her blood pressure is stable, so the patient is  sent home at 10:23 p.m. Wednesday. Is this an established outpatient visit or an observation E/M service?

California Subscriber

Answer: It depends on whether or not the patient was designated as "observation status." If so, report the following:

• 99235 (Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date, which requires these 3 key components: a comprehensive history; a comprehensive examination; and medical decision making of moderate complexity ...) for the observation service
• 276.51 (Disorders of fluid, electrolyte, and acidbase balance; volume depletion; dehydration) appended to 99235 to represent the patient's dehydration
• 780.2 (Syncope and collapse) appended to 99235 represent the patient's syncope
• 487.8 (Influenza; with other manifestations) to reflect the patient's influenza as a causal factor leading to other manifestations (dehydration and syncope).

If the patient was not designated as "observation status," then you are left to code the encounter with an established outpatient visit code. Based on the level of history, exam, and medical decision making involved and given the patient's status as "established," 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requiresat least 2 of these 3 key components: a comprehensive history; a comprehensive examination; medical decision making of high complexity ...) might be appropriate in this instance.