Primary Care Coding Alert

Question: A mom brought her 4-year-old daughter in for painful vaginal area. The FP provided a level IV established patient visit and ordered a urinalysis and pulse oximetry test. The patient had a low PO, and the FP ordered a nebulizer treatment with Xopenex. The urinalysis came back negative, and the physician had the specimen sent out for further growth and culturing. I received a denial for the urinalysis. Did I code the following items incorrectly?

Answer:

Asthma (493.90, Asthma, unspecified) does not relate to the urinalysis (81001, Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; automated, with microscopy) and specimen handling (99000, Handling and/or conveyance of specimen for transfer from the physician's office to a laboratory). Refile the urinalysis and specimen handling charges and link them to a secondary diagnosis of vaginal pain (such as 625.9, Unspecified symptoms associated with female genital organs). Enter diagnosis 2 in Box 21. Relate 81001 and 99000 to 625.9 by entering "2" the number (not the code) of the related ICD-9 code from box 21 in Box24E.

The selected level of E/M service (99214-25, Office or other outpatient visit for the evaluation and management of an established patient ...; Significant separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) would be better supported if you listed 625.9 as a secondary diagnosis. Including both 493.90 and 625.9 shows the complexity of the service from the added history, evaluation, and medical decision making necessary to address both problems. Some payers look at only the primary diagnosis, so some practices are in the habit of submitting only the top ICD-9 code. Reporting all documented and non-inherent diagnoses paints a more accurate picture.

The other items " 94640 (Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes [e.g., with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing [IPPB] device), 94760 (Noninvasive ear or pulse oximetry for oxygen saturation; single determination), J7614 (Levalbuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose, 0.5 mg) are correct and appropriately relate to the indicated diagnosis of asthma.