Pulmonology Coding Alert

After spending almost an hour stabilizing an acute asthmatic, an extra $60 can be in store provided you make the right choice between coding prolonged services or a higher-level E/M.

Case study: A patient requires two nebulizer treatments and lengthy evaluation time due to an exacerbation of asthma (493.02, Extrinsic asthma; with [acute] exacerbation). Which of the following E/M options would you report:

A. 99214 -- Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; medical decision making of moderate complexity ... Usually, the presenting problems are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family.

and +99354 -- Prolonged physician service in the office or other outpatient setting requiring direct (face-toface) patient contact beyond the usual service; first hour (List separately in addition to code for office or otheroutpatient Evaluation and Management service)

and 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]);

94640-76 (Repeat procedure or service by the same physician) for the two nebulizer treatments.

B. 99215 -- Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a comprehensive history; a comprehensive examination; medical decision making of high complexity ... Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family.

and 94640, 94640-76 for the two nebulizer treatments.

A University of Utah coder has been receiving payback requests for prolonged services due to not meeting the service's time threshold. The physicians had reported +99354s with 99214s based on performed and documented key components. Before coding the prolonged service, make sure you count time using these guidelines:

• Count only minutes beyond the typical time that CPT designates for that E/M service. "For a 99214 that meets the key components, you would back out 25 minutes before adding on prolonged services," explains Peter Hollmann, MD, medical director for Blue Cross and Blue Shield of Rhode Island.

• In the outpatient setting, you can count only face-toface time the physician spends directly with the patient. To support +99354 with 99214, the physician would have to spend at least 30 minutes beyond 99214's typical time of 25 minutes -- or at least 55 minutes -- directly with the patient in E/M services.

• Do not include time performing procedures toward the prolonged services time. With an asthmatic attack in the office, you would exclude minutes spent performing nebulizer treatment(s) (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]) and pulse oximetry (such as 94761, Noninvasive ear or pulse oximetry for oxygen saturation; multiple determinations [e.g., during exercise]) from qualifying for +99354 time.

• Time can be non-continuous. For instance, evaluation and management before and after a nebulizer treatment (94640) can count toward prolonged services (+99354).

If you document the time correctly (as noted above), this encounter will most likely qualify for a level-four established patient office visit (99214) with prolonged services (+99354), rather than a level-five office visit (99215), says Donelle Holle, RN, in Fort Wayne, Ind. The 99214 visit includes 25 minutes of face-to-face time, with the additional 35 minutes meeting the "greater than 30 minute" requirement for billing +99354.

You probably won't have enough history, evaluation, and medical decision making (MDM) to justify 99215. "Asthmatic attacks may only involve a detailed history and a detailed exam, despite high-complexity medical decision making," Holle says. These key components would not support 99215.

"The other way to reach 99215 is for counseling to comprise more than 50 percent of the physician-patientface-to-face encounter," Holle adds. Counseling does not typically dominate acute asthmatic attack encounters.