Pulmonology Coding Alert

Get the most out of claims for anaphylaxis reaction

When your pulmonologist treats allergy patients for anaphylaxis reaction, you should know when to choose critical care codes (99291-99292) rather than other E/M codes and how the visit's time affects your coding choices. 
 
Review the following three critical care questions and answers offered by our coding experts to improve your E/M coding accuracy.

1. Why should we use critical care codes rather than other E/M codes?

Answer: Often pulmonology coders resist using critical care codes 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]) because they believe they are meant for hospitals.
 
You may use these high-paying codes in the office, however, 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. Also, most Medicare insurers pay more for 99291-99292 than for other E/M codes. For instance, HGSAdministrators (HGSA) in Pennsylvania pays about  $256 for 99291. On the other hand, if you submitted level-five new patient code 99205 to HGSA, you could expect about $180, a difference of $76. But to improve your reimbursement, you must medically justify using 99291-99292, or your insurer may deny your claim.

2. How can we determine when to report 99291-99292?

Answer: You should follow your pulmonologist's documentation and CPT's requirements for reporting critical care.
 
For example, a new patient presents to your pulmonologist with an anaphylaxis reaction to a bee sting (989.5) and then develops respiratory distress (786.09) and chest pains (786.50). The physician treats the patient for 45 minutes in the office before sending the patient to the emergency department. If the physician documents the visit, you should be able to report 99291 because the visit  lasted longer than 30 minutes and was for a condition that impaired one or more vital organ systems. (For more on critical care documentation, see "Report Critical Care With Confidence" on page 22.)

3. Can we still report critical care if a patient comes into the office with anaphylaxis reaction and responds to treatments within a few minutes? 
 
Answer: Make sure your pulmonologist spent 30 minutes providing critical care to the patient, no matter how urgent the patient's condition, coding experts say.
 
Often when a physician administers epinephrine (J0170) to a patient with anaphylaxis, the patient recovers before the visit qualifies for CPT's 30-minute requirement, says Susan Callaway, CPC, CCS-P, an independent coding and reimbursement specialist and educator in North Augusta, S.C.
 
If the physician's critical care services do not total 30 minutes, you should use the appropriate E/M code (99201-99205 and 99211-99215), according to CPT.
 
For instance, a 25-year-old female patient comes in after a yellow-jacket sting. The sting site shows generalized signs of swelling and redness. During the examination, the patient begins to wheeze, and her blood pressure drops. She shows signs of abdominal cramping and altered consciousness. The physician intramuscularly administers (90782, Therapeutic, prophylactic or diagnostic injection [specify material injected]; sub-cutaneous or intramuscular) 2.5 mg of dexamethasone acetate (J1094, Injection, dexamethasone acetate, 1 mg) and 0.18 ml of epinephrine (J0170, Injection, adrenalin, epinephrine, up to 1 ml ampule). 
 
After about five minutes, the patient's signs begin to subside, and the physician gives a shot of 25 mg of diphenhydramine hydrochloride (J1200, Injection, diphenhydramine HCl, up to 50 mg) and a nebulized albuterol treatment (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]). The patient's condition stabilizes in 15 minutes. The physician and a nurse monitor the patient for the next three hours. 
 
Although the patient's symptoms were initially life- threatening, the patient's organs have now stabilized prior to reaching the 30 minutes. The nurse will monitor the patient, but if the patient requires additional care, the physician must intervene.