Pulmonology Coding Alert

When an office visit turns to an emergency situation, know which codes to report.

Although it may not happen every day, pulmonologists do sometimes see patients whose conditions are so critical that the visit turns into an emergency situation. There are a few potential ways to code these visits, so it's important to know all the options before you submit your bill.

Scenario 1: Use An E/M Code

A patient presents to your practice for an allergy injection and has an anaphylactic reaction while she's in the office. The pulmonologist administers an epinephrine injection and stays with the patient until she stabilizes.

How should you code this? In this case, you'll report the physician services in addition to any applicable injection code(s), such as 95115 (Professional services for allergen immunotherapy not including provision of allergenic extracts; single injection; or 95120 (Professional services for allergen immunotherapy in the office or institution of the prescribing physician or other qualified health care professional, including provision of allergenic extract; single injection).

As in other situations when your pulmonologist provides an E/M service, such as established patient visit 99214 (Office or other outpatient visit for the evaluation and management of an established patient...), simultaneously with a procedure, you must append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to 99214.

Generally, your physician will treat the patient with epinephrine (which you can bill using HCPCS supply code J0171) and report the appropriate E/M service, such as 99214. If your patient has a severe reaction and spends a minimum of 30 minutes stabilizing the patient, your pulmonologist may document and report the critical care (99291-+99292) along with any other separately reportable services as necessary. In all cases, documentation should clearly explain the patient's condition to justify reporting the additional E/M code(s).

Scenario 2: Consider 99058

A new patient presents for asthma evaluation, but while in the hallway on the way to the office, the patient has an asthma attack. The pulmonologist goes into the hallway and attends to the patient, administering a bronchodilator until the patient is stabilized. The patient then comes into the office and the physician performs a level five evaluation.

How should you code this? Because the emergency treatment disrupted the physician's schedule, you should report 99058 (Office services provided on an emergency basis). If the physician interrupts the scheduled office appointments to see the patient, you'll report 99058 in addition to the E/M service, such as 99205 (Office or other outpatient visit for the evaluation and management of a new patient ...). You can also report any other services performed at the visit, such as the bronchodilator treatment.

Many coders shy away from using 99058 because Medicare considers this a "bundled" service and does not reimburse it; and many third-party payers follow suit. However, some other payers will reimburse you for it, so you should always check with your insurers about whether it's payable.

To help justify reporting 99058, encourage your physician to include the specifics of the emergency interruption. The documentation doesn't have to be extensive, and could be as simple as a note that says, "Had to treat emergency patient out of turn due to asthma attack."

Scenario 3: Report Inpatient Code

The physician is examining a COPD patient when the patient suddenly has a seizure and falls on the floor, where he hits his head. The pulmonologist administers emergency care while waiting for an ambulance to take the patient to the hospital.

How should you code this?  In most cases, you'll simply report a standard E/M code (99201-99215), provided the E/M service rendered and documented by the physician was appropriate for selecting that level of service based on the history, exam, and medical decision-making. The situation probably does not warrant critical care services (99291-+99292), and the emergency department codes (99281-99285) cannot be billed in the physician's office.

Alternative: If the pulmonologist subsequently sees the patient in the hospital and admits him later that same day, you should report only one E/M service per calendar day. Therefore, you'll include any outpatient services in your initial hospital care with a code from the 99221-99223 (Initial hospital care, per day, for the evaluation and management of a patient ...) range. Remember, however, that to report the initial hospital service (99221-99223), the physician must provide a face-to-face encounter in the hospital setting.